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Introduction: COVID-19 pandemic led to changes in healthcare provision across the NHS with large-scale implementation of telemedicine. We aimed to evaluate the feasibility, acceptability, patients’ convenience and satisfaction of telephone clinics in urogynecology during the initial stages of the pandemic. Methods: All consented patients scheduled for phone clinics were included. Descriptive statistics were used to analyze quantitative data and inductive thematic analysis for free-text comments. Results: 101/109 (93%) patients completed the survey. Median age (interquartile, IQR) was 60 years (IQR 21.5) and median consultation duration was 16 minutes (IQR 8). 33/101 (32.7%) were new cases and 13/101(12.9%) were tertiary referrals. To facilitate face-to-face appointments, 100/101 (99%) patients required transport and 30/101 (29.7%) needed time off-work. 98/101 (97%) of the patients were happy or very happy with phone consultation, with 91/101(90.1%) scoring 8-10 on Visual Analogue Scale (VAS). Conclusion: Urogynecology phone clinics are feasible, acceptable and convenient with high level of patients’ satisfaction. Robust studies are required to evaluate the feasibility of integrating telemedicine into routine urogynecology practice.

This was a retrospective study to review the uptake and outcomes of robotic gynaecological surgery in England between 1st April 2006 and 31st March 2018, analysing Hospital Episode Statistics form National Health Service hospitals in England. Women aged 18 years and above who had elective gynaecological surgery were included and those who had undergone robotic gynaecology surgery were included. Robotic gynaecological procedures were defined as procedures that used a robotic minimal access approach for hysterectomy, adnexal surgery and urogynaecological surgery (sacrocolpopexy, sacrohysteropexy and colposuspension). Numbers of procedures were reviewed by year and mapped to the 44 NHS healthcare regions. Length of stay (nights in hospital), laparotomy (conversion during primary procedure or after return to theatre for management of complication), and 30-day emergency readmission rates were calculated by year and procedure type. Overall 527,217 elective gynaecological procedures were performed in the English NHS (1st April 2006 and 31st March 2018), of which 4384 (0.83%) were performed with robotic assistance (3864 (88%) hysterectomy, 706 (16%) adnexal surgery, 192 (4%) urogynaecological surgery). There was gradual rise in the uptake of robotic surgery but there was a marked geographical variation. Median (IQR) length of stay (LOS) was 1(1-2) night, laparotomy rate was 0.3% and 30-day emergency readmission rate was 4.7%. LOS was statistically, but not clinically, different across time. Other outcomes did not differ by year. Robotic gynaecological procedures are increasingly being used in the English NHS, predominantly for hysterectomy, although in small proportions (2.6% in the most recent study year). There was wide geographical variation in robotic uptake across England and overall, outcomes were comparable to those reported in other countries.

Introduction The aim of this study was to determine how recommendations of gynaecologists on surgical treatment for stress urinary incontinence (SUI) were influenced by patient characteristics. Methods Two hundred forty-five gynaecologists in the UK fully responded to an online questionnaire including 18 vignettes describing 7 clinical characteristics of women with SUI (age, body mass index, SUI type, previous SUI surgery, frequency of leakage, bother, physical status). The gynaecologists scored recommendations for surgery ranging from 1 ‘certainly not’ to 5 ‘certainly yes’. Mean scores were used to calculate the relative impact (‘weight’) of each clinical characteristic. Latent class analysis was used to distinguish groups of gynaecologists with a particular practice style because they responded to the patient characteristics captured in the case vignettes in a similar way. Results The gynaecologists’ overall average recommendation score was 2.9 (interquartile range 2 to 4). All patient characteristics significantly influenced the recommendation scores (p always < 0.001) but their impact was relatively small. SUI type was most important (weight 23%), followed by previous SUI surgery (weight 21%). Latent class analysis identified five groups of gynaecologists with practice styles that differed mainly with respect to their mean recommendation score, ranging from 1.3 to 4.0. Conclusions Surgical treatment advice in response to case vignettes was only minimally influenced by patient characteristics. There were five groups of gynaecologists whose inclination to recommend surgical treatment varied. This suggests that there is lack of consensus on the role of surgery as a treatment for SUI. A considerable number of gynaecologists were reluctant to recommend surgery.

Background The rapid uptake of robotic surgery has largely been driven by the improved technical aspects of minimally invasive surgery including improved ergonomics, wristed instruments, and 3-dimensional vision. However, little attention has been given to the effect of physical separation of the surgeon from the rest of the operating team. Purpose The aim of this study was to examine in depth how this separation affected team dynamics and staff emotions. Methods Robotic procedures were observed in 2 tertiary hospitals, and laparoscopic/open procedures were added for comparison; field notes were taken instantaneously. One-to-one interviews with theater team members were audio recorded and transcribed verbatim. Qualitative analysis was conducted via grounded theory approach using NVIVO11. Results Twenty-nine participants (26 interviewed) were recruited to the study (11 females) and 134 (109 robotic) hours of observation were completed across gynecology, urology, and colorectal surgery.The following 3 main themes emerged with compounding factors identified: (a) communication challenge, (b) immersion versus distraction, and (c) emotional impact. Compounding factors included the following: individual and team experience, staffing levels, and the physical theater environment. Conclusions Our emergent theory is that "surgeon-team separation in robotic theaters poses communication challenges which impacts on situational awareness and staff emotions." These can be ameliorated by staff training, increased experience, and team/procedure consistency.

Introduction and hypothesis Health literacy underpins informed consent and shared decision-making. In gynaecology, this includes understanding of normal anatomy and urogenital disease. This study evaluated public knowledge of external female genital anatomy and pelvic organ prolapse (POP). Methods A questionnaire study asked participants for their demographics and to label a female external genitalia diagram and included free-text questions on POP, its symptoms and treatment. Questionnaires were distributed at general outpatient (OPD) and urogynaecology (UG) departments at a UK teaching hospital. Differences in the number of correct anatomy labels between participant genders were assessed via chi-squared tests and, within female participants, multivariable linear and logistic regressions assessed associations with increasing correct anatomical labels and an understanding (versus no understanding) of POP, respectively. Results Within 191 (n = 160 OPD, n = 31 UG), 9/103 (9%) labelled all anatomical structures correctly. Females had more correct labels (median 1, IQR 0,3) versus males (median 0, IQR 0,1), P = 0.022). Higher education (vs. P = 0.024, 1.45 (0.58, 2.33), P = 0.001 respectively]. Fifty-three per cent understood POP. POP understanding increased with increasing age, white ethnicity (OR: 4.38, 95% CI: 1.36, 14.08, P = 0.013) and more correct anatomy labels (OR: 1.43, 95% CI 1.14, 1.79, P = 0.002). Of those who understood POP, only 35% identified “bulge” as a symptom and 7% physiotherapy as a treatment option. Conclusion There was poor public understanding of external female genital anatomy and POP, which may have significant implications for health-seeking, shared decision-making and informed consent.

AIMS: To determine terminology and methods for raising intra-abdominal pressure (IAP) currently used by clinicians to assess pelvic floor dysfunction (PFD) and to measure the effect of these maneuvers on IAP. METHODS: Three-hundred questionnaires were distributed at two scientific meetings in the United Kingdom to determine methods clinicians used to raise IAP and their perceptions of these methods. Twenty healthy volunteers were also recruited to measure the effect of two methods of raising IAP: Valsalva maneuver (VM) and bear down maneuver (BDM). IAP pressure was measured with rectal catheters connected to pressure sensors. The IAP was measured during each maneuver in both standing and supine positions. RESULTS: Maneuvers used in practice were cough (79%), BDM (60%), and VM (38%). 44% of clinicians felt patients found it difficult to raise their IAP. There was uncertainty among clinicians as to which method was the most effective in raising IAP and whether the different methods produced the same rise in IAP. On testing IAP in 20 healthy volunteers, median (interquartile range) IAP generated during BDM; 101 (59.1) cmH2 O was significantly higher than that generated during VM; 80.3 (43.6) cmH2 O (p < .0001). CONCLUSION: Clinicians varied widely in the maneuvers they used to raise patients' IAP to test for PFD and there was uncertainty about the maneuvers' effect on IAP. In healthy volunteers, BDM produced significantly higher IAP than VM. We recommend standardization of terminology and techniques used to raise IAP when assessing PFD, to ensure consistency of diagnosis and assessment of treatment outcomes.

Introduction and hypothesis There is a lack of robust evidence guiding treatment options for recurrent stress urinary incontinence (SUI) and limited comparative outcome data. The aim of this study was to examine the pattern of surgery for recurrent SUI performed by gynaecologists in the UK and compare subjective success rates. Methods Retrospective review of the British Society of Urogynaecologists database for patients having repeat incontinence procedures (2007–2015) including the number of each procedure and outcome recorded by the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) questionnaire. Procedures were compared by year and outcomes by operation. Categorical comparisons were performed using Chi-squared test and numerical comparisons using appropriate non-parametric tests. Results A total of 2,938 records were obtained (269 were excluded) and 2,164 women (88.8%) had undergone one previous procedure, most commonly retropubic midurethral sling (MUS; 28.6%). Pelvic floor exercises were offered to 76.2% women. Urodynamic investigation was carried out in 96.2% women: 76.5% had urodynamic stress incontinence. Repeat MUS was the most common procedure (77.3%), followed by bladder neck injections (BNI; 10.2%). Follow-up details were available for 66.1%. Outcome data were poorly reported. Median ICIQ-UI-SF score fell from 16 (0–21) to 0 (0–21) (p p Conclusion MUS and BNI were the most common repeat continence procedures. Follow-up data suggest that MUS, colposuspension and fascial sling are most effective.

The rapid uptake of robotic surgery has largely been driven by the improved technical aspects of minimally invasive surgery including improved ergonomics, wristed instruments, and 3-dimensional vision. However, little attention has been given to the effect of physical separation of the surgeon from the rest of the operating team.The aim of this study was to examine in depth how this separation affected team dynamics and staff emotions.Robotic procedures were observed in 2 tertiary hospitals, and laparoscopic/open procedures were added for comparison; field notes were taken instantaneously. One-to-one interviews with theater team members were audio recorded and transcribed verbatim. Qualitative analysis was conducted via grounded theory approach using NVIVO11.Twenty-nine participants (26 interviewed) were recruited to the study (11 females) and 134 (109 robotic) hours of observation were completed across gynecology, urology, and colorectal surgery.The following 3 main themes emerged with compounding factors identified: (a) communication challenge, (b) immersion versus distraction, and (c) emotional impact. Compounding factors included the following: individual and team experience, staffing levels, and the physical theater environment.Our emergent theory is that "surgeon-team separation in robotic theaters poses communication challenges which impacts on situational awareness and staff emotions." These can be ameliorated by staff training, increased experience, and team/procedure consistency.

Importance There is concern about outcomes of midurethral mesh sling insertion for women with stress urinary incontinence. However, there is little evidence on long-term outcomes. Objective To examine long-term mesh removal and reoperation rates in women who had a midurethral mesh sling insertion for stress urinary incontinence. Design, Setting, and Participants This population-based retrospective cohort study included 95 057 women aged 18 years or older who had a first-ever midurethral mesh sling insertion for stress urinary incontinence in the National Health Service hospitals in England between April 1, 2006, and December 31, 2015. Women were followed up until April 1, 2016. Exposures Patient and hospital factors and retropubic or transobturator mesh sling insertions. Main Outcomes and Measures The primary outcome was the risk of midurethral mesh sling removal (partial or total) and secondary outcomes were reoperation for stress urinary incontinence and any reoperation including mesh removal, calculated with death as competing risk. A multivariable Fine-Gray model was used to calculate subdistribution hazard ratios as estimates of relative risk. Results The study population consisted of 95 057 women (median age, 51 years; interquartile range, 44-61 years) with first midurethral mesh sling insertion, including 60 194 with retropubic insertion and 34 863 with transobturator insertion. The median follow-up time was 5.5 years (interquartile range, 3.2-7.5 years). The rate of midurethral mesh sling removal was 1.4% (95% CI, 1.3%-1.4%) at 1 year, 2.7% (95% CI, 2.6%-2.8%) at 5 years, and 3.3% (95% CI, 3.2%-3.4%) at 9 years. Risk of removal declined with age. The 9-year removal risk after transobturator insertion (2.7% [95% CI, 2.4%-2.9%]) was lower than the risk after retropubic insertion (3.6% [95% CI, 3.5%-3.8%]; subdistribution hazard ratio, 0.72 [95% CI, 0.62-0.84]). The rate of reoperation for stress urinary incontinence was 1.3% (95% CI, 1.3%-1.4%) at 1 year, 3.5% (95% CI, 3.4%-3.6%) at 5 years, and 4.5% (95% CI, 4.3%-4.7%) at 9 years. The rate of any reoperation, including mesh removal, was 2.6% (95% CI, 2.5%-2.7%) at 1 year, 5.5% (95% CI, 5.4%-5.7%) at 5 years, and 6.9% (95% CI, 6.7%-7.1%) at 9 years. Conclusions and Relevance Among women undergoing midurethral mesh sling insertion, the rate of mesh sling removal at 9 years was estimated as 3.3%. These findings may guide women and their surgeons when making decisions about surgical treatment of stress urinary incontinence.

The aim of this study was to assess the incidence of stress urinary incontinence (SUI) following laparoscopic sacrocolpopexy in continent women and its relation to postoperative prolapse stage. A total of 220 continent women with symptomatic apical prolapse who underwent laparoscopic sacrocolpopexy were prospectively evaluated; 100 women had previous hysterectomy. Patients were followed up at 3 and 12 months after surgery. All subjects completed the King’s Health Questionnaire (KHQ) and Prolapse Quality of Life Questionnaire (P-QOL) and were examined using the Pelvic Organ Prolapse Quantification (POP-Q) system. The primary outcome measure was the number of women who developed new onset moderate/severe SUI at 3 and 12 months postoperatively and its relation to postoperative prolapse stage. At 3 months, 52 women (23.6 %) developed moderate/severe SUI; 27 (12.2 %) had severe SUI. Eleven women (5.0 %) underwent surgery for SUI within 6 months of sacrocolpopexy. All surgery for SUI was in women who had post-hysterectomy sacrocolpopexy. Postoperatively, the vaginal apex (point C) was at stage 0/I in 195 cases (88.6 %). There were no differences in postoperative POP-Q stage of the anterior and apical vaginal walls between continent women and those with SUI (p = 0.45). The posterior vaginal wall was higher in women who developed de novo SUI (p = 0.03). The incidence of SUI following apical prolapse repair is 23.6 %. Subsequent continence procedures were performed in 5.0 % of patients. All were in women who had previous hysterectomy making the risk in this group 11 %. Higher POP-Q stage of the posterior vaginal wall was associated with SUI.