Midurethral slings are currently considered the gold standard for treatment of stress urinary incontinence. The retropubic midurethral sling, commonly known as the TVT, has a success rate of 81% as reported in the TOMAS trial. Advantages include short operating time, rapid recovery, and low cost. Possible complications include voiding dysfunction, vascular or bowel injury, mesh exposure, pelvic pain, urethral injury, and bladder perforation. This video focuses on bladder perforation as a complication that is preventable with proper surgical technique. When a bladder perforation occurs, operating time is increased and the patient is required to maintain a Foley catheter for a longer period of time. This may lead to increased rate of urinary tract infections as well as discomfort and anxiety for the patient. According to one retrospective review of over 1,500 procedures, novice surgeons are thought to have the highest perforation rates. Resident physicians likely account for a significant portion of the bladder perforation rate given high TVT utilization in teaching as well as community hospitals. At our academic institution, the bladder perforation rate from July 1, 2016 through June 30, 2017 was 11.9%. This is notably higher than the reported perforation rate for experienced surgeons, which has been cited at 5.1%. There is scant literature describing methods to teach residents the skills required for TVT placement. Though limited studies have described intraoperative teaching techniques and use of trainers to simulate TVT placement, there is no data directly linking such interventions to clinical outcomes. The objective of this video is to present an intervention aimed at decreasing the bladder perforation rates at a university hospital. An educational intervention consisting of a 10-minute instructional video and a low-fidelity preoperative simulation was implemented in residents rotating through urogynecology starting in December 2017. Interval data was collected at the conclusion of March 2018. Residents were required to view the instructional video online prior to their first TVT placement with entry of initials and date to confirm completion of this task. Five key steps to decrease the risk of bladder perforation identified by an expert pelvic surgeon were reviewed in the video. These steps included, 1, abdominal incisions, 2, vaginal incision and tunnel creation, 3, deflection of urethra, 4, placement of trocar and vaginal tunnel, and 5, trocar path. An abbreviated version of the intervention video highlighting these five key steps is shown here. Two 5-millimeter incisions are made 1 centimeter from the midline bilaterally at a level just above the pubic symphysis. Care is taken not to exceed a distance of 2 centimeters from the midline in order to avoid nerve injury. These incisions represent the sites where the TVT trocars will exit after passage through the retropubic space. A midline incision is made sharply in the vaginal epithelium and superficial vaginal muscularis starting 1 centimeter below the external urethral meatus and is extended 1.5 centimeters posteriorly from this point. From this midline incision, bilateral periurethral tunnels are created leading to the inferior pubic rami. To aid in the creation of these tunnels, the index finger of the non-dominant hand can be used to guide metzenbaum scissors posterolaterally until the inferior pubic ramus is reached. A rigid guide is placed through the Foley catheter and a surgical assistant uses the catheter guide to deflect the urethra to the contralateral side in order to lower the risk of urethral injury. Next, the trocar needle is aligned with the periurethral tunnels created in the previous step. The non-dominant index finger is used to guide the trocar needle through the tunnel to the inferior pubic ramus. To pass the trocar through the retropubic space, it is important to keep the index finger of the non-dominant hand fixed against the internal aspect of the inferior pubic ramus. This vaginal hand controls the direction of the needle. The needle is then curved upward toward the ipsilateral abdominal incision, perforates the periurethral tissue just behind the pubic bone, and enters the retropubic space. If passed correctly, the trocar should progress smoothly through the endopelvic fascia and the rectus muscle. If the TVT trocar is angled prematurely, you risk hitting the pubic bone and will not be able to pass the trocar through the endopelvic fascia. If aimed too far cephalad or passed with excessive force, the bladder may be perforated. If deviated laterally, injury to the external iliac vessels or obturator neurovascular bundle may occur. After the needle perforates the abdominal wall, the Foley and catheter guide are removed and cystourethroscopy is performed to confirm correct placement and evaluate for bladder or urethral perforation. Once correct needle placement is confirmed, the introducer is removed, needles cut, and mesh tensioned with the aid of a hemostat or curved Mayo scissors. The mesh is trimmed and the skin incisions are closed. Prior to each surgical case, residents were required to replicate simulation of TVT trocar passage on a simple bony pelvis model as demonstrated in the intervention video. A faculty member or fellow in the urogynecology department witnessed each demonstration by the resident and evaluated his or her ability to correctly simulate the TVT trocar path. Faculty or fellow approval of correct demonstration was documented on a data sheet where residents also recorded the date of procedure, patient medical record number, and presence or absence of a bladder perforation along with any comments. Information provided was cross-checked via retrospective chart review comparing the resident data sheet with documentation in the electronic medical record for accuracy. Resident compliance with study protocol was also assessed at this time. Data over a four-month period was reviewed with the following findings. A total of 39 TVT procedures were performed, of which two were excluded from analysis because they were performed by staff, fellows, or residents who were not currently on the urogynecology rotation. The intervention was not carried out in one case secondary to resident noncompliance. The intervention was successfully implemented in a total of 36 TVT cases. 39% of participating residents were in their second year of training and 61% were in their third year. Of 36 total cases performed by residents, two perforations occurred at a rate of 5.6%, effectively decreasing the perforation rate by 52.9%. In conclusion, preliminary data on an instructional video and preoperative bony pelvis simulation show greater than a 50% reduction in bladder perforation rate among residents at a university hospital. We predict feasible implementation and high compliance when instituted in residency training programs due to the efficient and inexpensive nature of this intervention.

bladder perforation

midurethral sling surgery

stress urinary incontinence

educational intervention

resident physicians