Thanks for giving us the opportunity to present our work. These are our disclosures. Training and promotion of vaginal surgery is the primary objective of ACOG due to the improved safety profile and patient outcomes. However, difficulty with visualization and understanding of vaginal procedures limit learners' experience and creates barriers to optimal mentoring and teaching of these surgeries. Independently mounted high definition cameras have improved the visualization and teaching of procedures within the operating room. The VTOM system combines an exoscope with a high definition video camera system that can be table mounted, negating the need for the learner or the surgeon to hold the camera or the need to mount the camera behind the surgeon, which can limit an ergonomic working environment. So the objective of our study was to compare learner satisfaction and experience among medical students and resident learners with a live projected high definition telescopic camera system to traditional learner surgery observation practices during vaginal surgery. We hypothesized that the projection of the images from the VTOM camera live within the operating room would improve learner satisfaction above traditional surgical learning during vaginal reconstructive surgery. An appropriate power analysis was performed and achieved, and learners were randomly allocated in a one-to-one ratio to the use of the VTOM camera and to traditional observation without the use of the VTOM camera. The primary outcome was the proportion of learners very satisfied in the faculty perceptive domain of the Veteran Affairs Learner's Perception Survey. To be included in the study, participants had to be a medical student or a resident and available to observe and participate in the surgery. Learners were excluded if they were performing a role within the surgery that precludes participation or participation would compromise the quality of surgery or patient safety. Immediately following surgery, learners completed questions on their characteristics, prior experience with vaginal surgery, interest in observing or performing vaginal surgery, and answered questions developed from the faculty perceptor and working environment domains of the VALPS using a five-point micro scale. The learners completed true or false questions on the ability to follow the procedural steps, see what the main surgeon was doing, ease of positioning themselves during the surgery, help with the surgery if needed, and the operating room was set up well for them to see the surgery. The learners also rated their overall satisfaction with learning in the operating room using a 100-millimeter visual analog scale with descriptive anchors at the extreme ends and a harsh mark in the center indicating neutral. 94 learners were enrolled and randomized. 44 were analyzed in the VTOM group, and 48 analyzed in the no VTOM group. Learners in the VTOM group reported a lower level of interest in observing or performing vaginal surgery in the present rotation. However, there were no significant differences between the two groups in the other demographic or training characteristics. For the primary outcome, the proportion of learners very satisfied with the faculty perceptor domain of the VALPS did not differ between the groups. And VTOM use did not demonstrate a difference in the overall satisfaction in the working environment domain. Learners in the VTOM group were more likely to report better ability to see what the main surgeon was doing well throughout the surgery and found it easy to position themselves to see what was happening in the surgery. They also found it easy to position themselves well to help with the surgery if needed and thought that the operating room was set up well for them to see the surgery. When they were asked to rate their satisfaction on the 100-millimeter visual analog scale, the learners in the VTOM group reported a higher satisfaction. So in conclusion, there were no significant differences in the overall satisfaction on the validated Likert scale question using both the faculty perceptor and working environment domains of the VALPS. And the medical students and resident learners were more satisfied with overall learning experiences in the operating room. Thank you. These are my references. All right, a descriptive analysis of cystoscopic images in interstitial cystitis potential applications of pattern recognition software in urogynecology. Dr. Adlo Dugina. Hi. I'm Paulina. Thank you very much for the opportunity to present our work. We have no relevant financial disclosures to disclose. Clearly, we have a little bit of a mouthful in terms of our title. So I wanted to break it down a little bit for you in terms of what we wanted to do. Some of you may have seen this painting before. And it's here at the Art Institute of Chicago. But what it shows is this is, in large ways, a way that Surratt was able to take those individual pieces of paint to create an overall image. This is very much the way that computers today also allow us to see pictures through the use of pixels. So what I wanted to do in the study was to look at cystoscopic images and pixels and decide if I figure out a way to quantifiably extract data from each of those images. So we know now that there are increasing numbers of computer algorithms and programs that are constantly being developed in medicine with wide applications. And every day, our ability to store large quantities of complex medical images and data is increasing as our technology advances. What we wanted to do is we wanted to apply this to study of interstitial cystitis. So this is a condition which is poorly understood, but one in which images from cystoscopy may aid clinicians in diagnosis. So what we did, or what we attempted to do, was to reliably and objectively extrapolate numeric data from two-dimensional cystoscopic images. Then we wanted to, furthermore, demonstrate quantifiable differences between images obtained from healthy individuals and individuals with interstitial cystitis or with painful bladder syndrome. To do this, we queried peer-reviewed images pertaining to cystoscopy and interstitial cystitis in the Journal of Urology and in Female Public Medicine and Neurogynecology. And then we used the open source program Python, which is an imaging processing program, where we built a computer algorithm to generate data from histograms in each image. So going back to that painting, what we did was we looked at each pixel that was used to compose the image. And from those pixels, we converted the tonality on a grayscale, on an 8-bit integer scale, into a value from 0 to 255. So in computer language, 0 is absolute black, and 255 is absolute white. So just to kind of illustrate this in a simplistic way, we have our original color image. And here's our 8-bit grayscale. 8-bit just basically means the full scale of grayscale image that computers can currently process and the human eye can distinguish. From that, we then extrapolated further to a central focus of the image. So we chose a 100 by 100 pixel area, which we included in our analysis. And each of the pixels within this was then used to generate a histogram. And from that, we used very simple statistics to just calculate mean, median, mode, and standard deviation of our values. So what we found is that after querying all of the journals that we discussed, we found 24 images that were described as IC or as PBS. And four images which could be included as controls or healthy individuals. We found that there was a difference with the average tonal value of the pixels in IC being a little bit darker at 193 with a higher standard deviation than the control images, which was 217 with a standard deviation of 45.8. What that means is that in pathology, we have darker images, and we have a wider distribution of the colors or the tonality within each image. We don't have p-values here because we don't really know what a significant difference is necessarily at this point. So here we were, though, able to at least build a framework of a simple method to derive objective data from digital images. We were able to demonstrate an objective difference, then, between normal images and pathology in a very small pool of peer-reviewed images. And so furthermore, we believe that with systematically collected cystoscopic images, we can use pictures like this to further develop algorithms in the future to help us analyze these pictures and hopefully use this to guide clinical decisions. And these are our references. Thank you. So thank you for providing the opportunity to present my study, Development and Validation of a Mobile Application Patient Decision Aid for Women with Overactive Bladder. And we have no disclosures. Treatment options for overactive bladder are complex and vary widely in efficacy, invasiveness, and side effect profiles. Decision aids are tools designed to help patients participate in the clinical decision-making process and make informed choices consistent with the patient's The use of mobile health care has become the forefront of delivering health care information. Thus, the aim of our study was to develop and validate a mobile application patient decision aid for treatment decision-making in women with overactive bladder. We performed a mixed-method study. In phase one, we conducted cognitive interviews to elicit information sources and information needs in women. And in phase two, we validated the MPDA tool by conducting a clinical trial. In phase three, we validated the MPDA tool by conducting a prospective cohort study. We conducted hour-long, semi-structured interviews with women with overactive bladder. And a priori, we planned to conduct interviews until saturation of themes was met or no new concepts emerged. Principles of qualitative somatic analysis were used to analyze this data. All women stated that they used the internet as their primary source of information. And almost all women were dissatisfied with the information sources they received, stating, you can't really believe everything you read online. I can't ask questions to the pamphlet, and I think ads on TV are criminally misleading. Information needs were also multifaceted. Women wanted visual information with active engagement to supplement the verbal advice they obtained from their providers. In particular, women placed a high value on personalization of the information, stating, I want to know about all treatments, but particularly the ones that work for my case. Using these results, we built a mobile patient decision aid with ability to compare treatment options and a customized feature allowing the application to tailor treatments based on personal history. In phase two, we aimed to validate it. Women seeking treatment for overactive bladder initially completed a decisional conflict scale. Second, they were instructed to use the MPDA without guidance and complete a second DCS. Lastly, they met with the provider and then completed a patient satisfaction questionnaire. The DCS is a validated questionnaire designed to evaluate personal perceptions of uncertainty, modifiable factors contributing to uncertainty, and effective decision making. Higher scores indicate greater decisional conflict. Women also completed the patient satisfaction questionnaire, a validated tool designed to evaluate global satisfaction within seven aspects of medical care. Here, higher scores reflect greater satisfaction. To assess construct validity, we compare DCS scores before and after MPDA use. To assess concurrent validity, we compare the relationship between the change in DCS score and the PSQ. And to assess discriminant validity, we compare the relationship between the change in DCS score in women who had failed two or fewer treatments versus those who had failed three or more. Pre-MPDA scores showed decisional delay or scores greater than 37.5, and post-MPDA scores showed implementation of decisions. After MPDA use, the decisional conflict scores improved in all sub-scores. The largest change was seen in the informed sub-score. Change in DCS was moderately correlated with total patient satisfaction score. Time spent with doctor had highest satisfaction sub-score and the strongest correlation with change in DCS score. Technical quality and accessibility and convenience had greater satisfaction scores and were moderately correlated to change in DCS. And for discriminant validity, women with greater than three failed prior treatments had greater changes in DCS than those with less than two prior treatments. Strengths of our study include the use of patient-centered narrative to inform the development of our MPDA and the use of a validated tool to measure decisional conflict. Limitations include the medium of a mobile application. It is also unclear whether these improvements will lead to improved adherence with selected treatment. Our cognitive interviews reveal that women remain deeply concerned about the potential adverse effects of treatments. An evidence-based MPDA developed with patient input is a valid tool for reducing decisional conflict. Our study also shows that the MPDA improves patient satisfaction with physician counseling and suggests that women who are better informed about treatment options and have less decisional conflict are more likely to report encounters with their physicians as positive. Thank you. To Dr. Andy and the Urabein team. All right, and our next presenter will be Dr. Grimes talking about validation of electronic, web-based and smartphone administration of measures of pelvic floor dysfunction. Thank you. I'm honored to be presenting on behalf of my team in the Collaborative Research and Pelvic Surgery Consortium. And these are some of our individual disclosures. So our objective is to correlate responses on electronically administered validated instruments of pelvic floor dysfunction to responses when administered on paper. So basically, we were looking at four instruments of pelvic floor dysfunction and comparing electronic versus paper. For electronic formats, we looked at a web-based format and we chose REDCap, which is a browser-based database. And you can see here an example of what the PFDI-20 looks like when you log on to REDCap and answer the questions. We worked with a software developer to create a smartphone iPhone app called Pelvic Tracker. Actually, I went through a few different iterations but the most recent is Pelvic Tracker. And here you can see that the smartphone screen where you would answer yes or no. And if you answer yes, you indicate the level of bother and that takes you to the questionnaire. And we were looking to correlate these with the paper administration. So our study was conducted at five FPRS clinic sites. We recruited women who presented with pelvic floor disorders who would not be having interval treatment between taking the questionnaires and the two arms. The four questionnaires that we looked at were the PFDI-20, the PFIQ-7, the PISQ-12 and the Bristol Stuhl Scale. And here you can see our power analysis and the statistics that we used. After enrollment, our subjects were block randomized to the different institutions and they were randomized either to paper first or electronic first. If they were randomized to electronic arm, we just had a practical question. Do you have an Apple iPhone? And if you do, are you willing to download this free app onto your phone? And if they said yes, they completed the smartphone app as part of the electronic arm. And if they said no, they were logged onto RedCap and created the questionnaires there. And then there was at least a two week kind of washout interval period and then the subjects completed the other arm. So this is our study population. So 132 women completed both sets of questionnaires. They were post-menopausal, 58 years of age, predominantly a white population. And you can see they had a diversity of presenting pelvic floor disorders. And these are our results. So you can see that the four instruments that we looked at, the PFDI-20, PFIQ-7, PISQ and the Bristol Stuhl Scale. And in the last column, you can see our correlation, our R values. And they range from 0.58 for the Bristol Stuhl Scale up to 0.86 for the PISQ-12. And then you can see we also looked at the subscales for the PFDI-20 and the PFIQ-7. Some other questions that we asked were, were there any differences in the demographic information between those who completed the first and second round of questionnaires? We found that there wasn't. We also thought that perhaps age might impact the subjects who had the smartphone and completed the smartphone versus web-paced electronic version. We didn't find that was a factor. And then we also looked to see that the responses for each total scale and individual scale between the first and second administration, there was no difference between those. So in conclusion, we found a moderate to strong reliability between electronic and paper. And this supports prior work that was done showing a correlation between paper electronic versions of the PFDI-20 and the PFIQ. And it adds to the literature by demonstrating a strong correlation for the PISQ and the Bristol Stuhl Scale. So therefore, electronic questionnaires administered via a web or smartphone platform are an acceptable alternative to paper-based forms. And so this allows us to feel more comfortable using these both in our clinic and as a tool for research. Thank you. Thank you for the opportunity to present our work. We have no disclosures. We all know well that pelvic floor disorders impact a woman's quality of life and wellbeing. Women often report changing their behaviors or adopting new behaviors to cope with pelvic floor disorders. And some of these behaviors might include wearing pads, only shopping in stores with public restrooms, avoiding consumption of certain foods or beverages, wearing dark clothing and carrying changes of clothes, as well as possibly avoiding social or physical activities. We are still gaining understanding of how these behaviors relate to symptom bother. The Adaptive Behavior Index was developed and validated by the Pelvic Floor Disorders Network to measure these behaviors. Our aim was to describe the behavioral adaptations used by women with symptomatic pelvic organ prolapse and to assess the changes in these adaptations following surgical treatment. We hypothesized that the adaptive behaviors would decrease following surgery. This is a prospective cohort study of women with symptomatic prolapse undergoing surgery enrolled between 2008 and 13. And our primary outcome was the ABI. The ABI is a 17-item self-administered questionnaire with two domains, with an 11-item avoidance domain and a six-item hygiene domain, where higher scores indicate greater number of adaptive behaviors. It was validated in women with pelvic floor disorders and it demonstrated responsiveness to change. Our secondary outcomes included other pelvic floor quality of life measures and assessments were performed at baseline three and six months post-operatively. A total of 275 women had surgery for prolapse and were enrolled. 157 subjects had adaptation data for all three time points and are included in this analysis. Subjects had a mean age of 62 years. They were predominantly white with a median leading edge of prolapse of three centimeters. One third of subjects reported more than one social problem and 40% had had prior prolapse and urinary incontinence surgery. Subjects had a median of eight comorbidities and most reported having prolapse symptoms for a median of two years. These graphs illustrate the median adaptation scores for the hygiene domain on the left and the avoidance domain on the right. Scores in both domains decreased significantly following prolapse surgery. Subjects with improved hygiene or avoidance adaptation subscales, scores at three months, had lower UIQ and UID scores. So of all of the pelvic floor quality of life measures, the UIQ and the UID were the ones that were different in patients who did improve versus those who didn't improve in their adaptations. So this is a comparison of the three-month UDI and UIQ scores in women who, in the avoidance scale in women who did and did not improve following surgery with the UDI on the left and UIQ on the right. These are the comparisons of the three-month UDI and UIQ scores in the hygiene domain, again with the UDI on the right, and the UIQ on the left and the UIQ on the right. And both of these were significantly different between the women who did and did not improve in their adaptations. To further investigate what drove the changes in the adaptive scores following surgery, we examined the percentage of subjects with improvement in individual questions. And for the avoidance domain, 50% or more of subjects who had improved adaptations had improvements in the behaviors of needing to urinate whenever possible, avoid standing for long periods, limiting physical activity, and drinking less fluids. And in the hygiene domain, 50% or more of the post-operative subjects with decreased adaptations had improvement in always knowing or locating the nearest restroom and using sanitary napkins. So in conclusion, in women who undergo surgery for prolapse, adaptive behavior index scores improve following treatment. These improvements, the greatest improvements are in adaptations that relate to urinary symptoms as well as to physical activity. And we do need future studies to better understand what factors contribute to those who do not change their adaptive behaviors following surgery. Thank you. Thank you. Dr. Hegde, presenting on, let me see, make sure I get the title right. Yeah, I've moved around here. So Pelvic Bulge Maneuver Coupled with Simultaneous Biofeedback Regarding Pelvic and Abdominal Muscle Activity, a Prospective Pilot Study of a Novel Technique in Women with Dysfunctional Warning. Yeah, thank you. I thank the Oxford Scientific Committee for allowing me to present this paper on the Pelvic Bulge Maneuver Coupled with Simultaneous Biofeedback Regarding Pelvic and Abdominal Muscle Activity in Women with Dysfunctional Warning. So dysfunctional warning is abnormally learned behavior in neurologically normal women characterized by impaired relaxation of the pelvic floor during warning. In women with pelvic floor dysfunction responsible for dysfunctional warning, isolating appropriate pelvic muscles to relax may be difficult even with biofeedback without having an easily understandable maneuver to perform. So the objectives of this study was to evaluate efficacy of coupling a novel technique, namely Pelvic Bulge Maneuver, that is reverse Kegel, facilitated by lightly blowing through pursed lips with simultaneous biofeedback regarding abdominal and pelvic muscle activity in women with dysfunctional warning, and to determine whether it causes relaxation of pelvic floor, seen on pelvic floor EMG and anal manometric pressure recording, without abdominal straining, as seen on abdominal EMG, and also to understand whether the Pelvic Bulge Maneuver can eventually become a learned behavior without resorting to the blowing action through pursed lips. So it was a prospective small pilot study conducted in 16 neurologically normal women with diagnosis of dysfunctional avoiding in 2016-17. A detailed history, detailed examination, both urogynecological and neurological. PBR done twice, urine culture, upper tract ultrasound imaging, pre-day bladder diaty, hystoscopy when indicated, uroflumetric with surface EMG, and urodynamics form the basis of the diagnosis. Exclusion criteria was presence of prolapse or any pelvic surgery done before. 15 weekly biofeedback sessions were conducted, 30 minutes duration each. First, abdominal muscle activity biofeedback was provided by using abdominal service patch EMG leads. Pelvic muscle biofeedback activity was provided via anal manometry pressure reading. Additional pelvic muscle activity, that's EMG biofeedback, was provided by perineal surface electrodes in the last three sessions with Bluetooth-enabled remote wireless recording. The patient's sitting on a commode in the restroom in these sessions. The protocol consisted of 20 repetitions of 10 seconds bulge maneuver, that is lightly blowing through pursed lips, followed by 10 seconds rest, with simultaneous watching of the abdominal pelvic EMG activity and pelvic pressure on the monitor. Calling home workers was then prescribed. Three daily sessions of 10 repetitions of 10 seconds bulge and 10 seconds rest. One patient could not complete the therapy and was excluded from the study. Now, if you can see on this graph, you can see that the top panel is the abdominal EMG panel, and this is the anal manometry pressure recording. So if you realize, when I ask the patient to do the bulge maneuver, that is blow through the pursed lips, you can clearly see that the anal manometry pressure reading reduces. Let us see. If you can see the graph from below, you can see that A, if you see the A point, you can see that the pressure recording is reducing. At the same time, the woman is not straining during the bulge maneuver. You can see from the B point that the abdominal pressure is not increasing. If you see, during the initial stages of biofeedback, you see the C point, the woman lost her blowing because she lost breath during the session. So she let go of the blowing and that's where the pressure increased. And the D point, when I asked her to rest, you could clearly see the patient's resting pressure was noted to be raised. So you can clearly see that there is reduction in abdominal pressure recording. Also, if you see the surface EMG, you can clearly see that A is the surface EMG at rest, B is doing the blowing maneuver, and C, again, is at rest. So this provided biofeedback to the woman. I found that, if you can see this, she's squeezing. Relax. Bulge. You can see that she's relaxing. Bulge, bulge, bulge, bulge, bulge. Relax. Bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge. Relax. Yeah, so she's... Bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge, bulge. Relax. Yeah. Yeah, so the median intercoital range, age of the women was 38 by 14, and six women were postmenopausal. In all study patients, the bulge maneuver was associated with reverse Kegel motion of perineum, as could be seen visually. All patients showed quieting of the pelvic EMG and reduction pelvic pressure record during bulge maneuver. The abdominal EMG confirmed no straining in all patients. Three patients were unable to void prior to therapy, you know, for long periods of time, started voiding with PVR in two of less than 100 ml. In the last three biofeedback sessions, 12 patients, that is 80% of patients, were able to bulge the perineum without resorting to the blowing maneuver, as seen visually and on EMG without abdominals straining. So if you look at the voiding characteristics, if you look at the PVR, the frequency, the average flow rate, the flow time, and voided volume, was significantly reduced in the post-therapy session, and the P values were significant. The pelvic bulge maneuver, in conclusion, leads to relaxation of pelvic flow without abdominal straining. With practice, it becomes a learned behavior that the patient can perform at will after initial facilitation through light blowing through pursed lips. In addition to dysfunctional voiding, this double EMG-facilitated maneuver has potential in the treatment of many conditions associated with hyperactive pelvic floor, including constipation, sexual dysfunction, pelvic pain, and painful bladder syndrome. Thank you. Good afternoon. My co-investigator and I appreciate the opportunity to present our work. We have no conflicts of interest. Hysterectomy is the hallmark procedure of gynecologic surgery. In recent years, the number of hysterectomies performed nationally has fallen considerably, even as more cases are performed in an outpatient setting. This phenomenon then leads to alterations in the numbers of hysterectomies programs can provide to residents as learning opportunities. The American College of Graduate Medical Education establishes the number of procedures that the review committee believes to be acceptable minimal exposure, but the number of cases required for competency remains uncertain. A 2017 committee opinion recommends that the vaginal hysterectomy be the approach of choice whenever feasible, with laparoscopic hysterectomy being preferred to abdominal in cases where the vaginal approach is not feasible. We undertook a retrospective cohort study using a statewide database to estimate the hysterectomy volume in the first five years following residency and to determine if recent graduates utilize vaginal hysterectomy similarly to more experienced physicians. We obtained provider-identified, patient-de-identified case mixed data over 11 years from the Massachusetts Center for Health Information Analysis. Surgeons were identified by state license number and were cross-referenced with a data set of publicly available information. Providers with fellowship training were excluded. Surgically active gynecologists were defined as those who had performed either a hysterectomy or a non-obstetric dilation and curatage in the calendar year of interest. Our comparison cohort was those who had finished residency at least 20 years earlier, but were not yet 65 years old. From the over 89,000 hysterectomies in the data set performed by over 1,900 providers, we narrowed to include the simple hysterectomies performed by recent residency graduates practicing as OB-GYN specialists in the five years following training. For example, a surgeon completing residency in 2008 would have all hysterectomies she performed in 2009, 10, 11, 12, and 13 included in the analysis. This cohort was compared to a similarly sized group of veteran OB-GYNs. Recent graduates chose the abdominal route nearly half the time, with vaginal and laparoscopic chosen less commonly. Hysterectomy volume did not change significantly over these five years. Surgically active recent graduates performed a mean of about four hysterectomies in each of the first five years, although this distribution was right-tailed with a median experience of approximately two hysterectomies per year. The median number of vaginal and laparoscopic hysterectomies was zero for each of the first five years. In comparison, veteran attendings performed a mean of 20 and a median of 9.5 hysterectomies annually. This cohort accomplished hysterectomies vaginally 58% of the time, statistically significantly more often than recent residency graduates. We then sought to control for other factors to see if this discrepancy was based in patient differences or provider differences. Not surprisingly, prolapse as an indication for hysterectomy was strongly associated with the decision to perform vaginal hysterectomy. Even when controlling for this and other factors, however, veteran practitioners were nearly three times more likely than recent graduates to perform vaginal hysterectomy. Our study is both strengthened by and limited by the use of a large statewide case mix database. When looking at surgeons, there were rare cases in which our ability to accurately include or exclude surgeons was limited. In addition, there are characteristics unique to the state of Massachusetts, including its relatively good access to care, that limit the generalizability of our findings to other states. Finally, we believe that our findings lend support to the recent ACGME changes in minimum hysterectomy numbers, which emphasize minimally invasive approaches. In conclusion, surgically active recent graduates practicing as OBGYN specialists are performing a small number of hysterectomies annually. Their anemic vaginal hysterectomy numbers are notably different from senior counterparts, a gap which cannot be explained purely by differences in patient population. In comparison to veteran attendings, recent graduates may have trained at a time when fewer hysterectomies are performed, and that total is split over more modalities, making it inherently harder to gain proficiency. The concern is that a mean of four and a median of two cases annually in the first five years would severely limit even the best trained surgeon's ability to maintain these hard-earned skills. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

learner satisfaction

experience

medical students

resident learners

vaginal surgery

VTOM camera

traditional observation practices