Gretchen Collins, MD

4/13/16. DAY 4 AT SGS

A jam-packed day of sessions, posters, awards, and clinical updates

Our last educational day was kicked off by a fascinating lecture by Dr. Amy Park on the “Genetic Determinants of Pelvic Organ Prolapse in Women of European American Descent: The Women’s Health Initiative.” Dr. Park and her colleagues found that there is evidence of phenotypic and genotypic heterogeneity in patients with pelvic organ prolapse, and there were 4 genetic loci identified that correlated with prolapse. Any uterine prolapse was associated with a genome-wide significant intergenic variant on chromosome 13, cystocele was associated with LOXL2, and all prolapse was associated with BMP.

Surmounting surgical site infection

Dr. Sarah Andiman then gave a lecture on the effects of a perioperative bundle and offered timely feedback for surgical site infection (SSI) prevention in hysterectomy. We all know that wound infections are a major morbidity associated with surgery, and Dr. Andiman’s group at Yale found that, by implementing this prevention program, the surgical site infection decreased 52.8%. Another suggestion from the audience was to have all patients use chlorhexidine wipes the night before and morning of a surgery to decrease wound infection. Similarly, Dr. Ali Bazzi gave a lecture on “Chlorhexidine-Alcohol Compared with Povidone-Iodine for Surgical-Site Antisepsis after Abdominal Hysterectomy.” The chlorhexidine was associated with 30% lower odds of SSI compared with povidone-iodine, even though this group had several medical comorbidities and risk factors known for SSIs.

Oral poster presenters make several interesting points

Dr. Christopher Ripperda from UT Southwestern Medical Center in Dallas, Texas, found that medical comorbidities and the presence of detrusor overactivity and PVR are predictors of early postoperative voiding dysfunction following a midurethral sling placement. Dr. Nabila Noor then described a fabulous surgical alternative to the use of morcellation to remove the uterus after a supracervical hysterectomy. She described the technique for performing a posterior colpotomy and stated that patients who had a surgery performed at her institution using this technique did not experience increased postoperative pain or longer postoperative stay.

Dr. Jennifer Thompson then shed some light on a very important question related to the Sunshine Act: Are physicians including all of their disclosures when they submit articles to a conference? When the physicians who submitted an abstract to the Society of Gynecologic Surgeons (SGS) in 2015 were searched on the Centers for Medicare and Medicaid Services (CMS) website, 62% of them had incomplete disclosures, with a total of nondisclosed CMS transactions equaling $1.3 million. We can do better!

Status update: The FPRN and passing of the torch

Congratulations to Dr. Kristin Jacobs, the new Fellows’ Pelvic Research Network (FPRN) Chair! The morning session ended with an innovative video from Dr. Janet Li and colleagues on the “Use of Suprapubic Carter-Thomason Needle to Assist in Cystoscopic Excision of Intravesical Foreign Object.”

The winner of the Distinguished Surgeon Award was given to Dr. Javier Magrina, and the SGS gavel was passed on to Dr. Vivian Sung! Congratulations!

Dr. Stephanie Pickett kicked off the eighth scientific session with a study entitled, “Comparing Methods of NSAID Delivery for Postoperative Pain.” When she and her colleagues compared IV toradol to IV ibuprofen for postoperative pain control after urogynecologic surgery, they found that patients experienced similar rates of pain control and satisfaction regardless of the type of analgesia.

Why are patients being readmitted after gynecologic oncology surgery?

The answer to this question is important as readmission rates are being considered for physician and hospital reimbursement. Dr. MaryAnn Wilbur and colleagues looked at the rates of unplanned 30-day readmission in gyn oncology patients. The patients who were readmitted had the following characteristics: ovarian cancer, creation of ostomy, Charleston score >5, language barrier, and positive discharge screen. Gastrointestinal disturbance and SSI were the most common reasons for readmission, and the total readmission-related costs for these patients was about $4.5 million.

Considering tissue extraction, surgical complications, and cognitive impairment

We then had 3 fabulous oral poster presentations. Dr. Emily Von Bargen and colleagues presented a study entitled, “Prevalence of Occult Pre-malignant or Malignant Pathology at the time of Uterine Morcellation for Benign Disease.” They performed a multicenter retrospective cohort study and found that 1.2% of women had a premalignant or malignant uterine pathology after surgery, with a prevalence of 0.66% of occult malignancy. She was unable to identify risk factors for those patients who had a premalignant or malignant pathology. Overall she found a low prevalence of premalignant or malignant uterine pathology when uterine morcellation was performed for benign disease.

Dr. Alix Leader-Cramer from Northwestern University pointed out “risk factors for a 30-day perioperative complications for total vaginal hysterectomy,” including chronic steroid use, higher ASA classification, current smoking status, diabetes, and lower preoperative serum albumin and sodium levels. Adnexectomy and resident participation were also associated with increased perioperative complications. About 9.5% of patients had a perioperative complication in the study population studied.

Finally, Dr. Elisa Trowbridge pointed out in her talk, on “Cognitive Impairment among Elderly Urogynecologic Patients,” that cognitive impairment is very prevalent among such women aged older than 75 years, and the Mini-Cog is a feasible screening tool.

What a way to end an AMAZING conference!

The conference ended with a fabulous video presentation by Dr. Andrea Benton, entitled “Surgical Approaches to the Management of Bladder and Ureteral Endometriosis.” Overall, the themes of this year’s SGS conference were to:

• emphasize the importance of performing a vaginal hysterectomy when feasible
• continue to strive to balance innovation with experimentation
• ensure that patients are being operated on by surgeons who are competent and frequently performing the indicated procedure.

Thank you to everyone who shared their research to educate the attendees at the conference! I can’t wait until next year!

4/12/16. DAY 3 AT SGS

Vaginal hysterectomy, fecal incontinence, transgender surgery amid tackled topics in Palm Springs

I could get used to sipping my coffee with the sunny background here in Palm Springs! It was a beautiful morning to learn.

We started the day with breakfast and a fabulous lecture on the inferior gluteal neurovascular anatomy in female cadavers, and an insightful lecture by Dr. Bhumy Dave, who brought up concerns about tracking for obstetrics and gynecology residency programs. She specifically highlighted the need for more experience with vaginal hysterectomies for residents who are going to be in a subspecialty that performs vaginal surgery. As the number of hysterectomies, specifically vaginal hysterectomies, declines every year, we need to make sure we are adequately training the physicians who will be performing this procedure in the future. One solution is to have residents join a track their 4th year of residency, after their future career path has been established. Another possible solution would be to increase use of a simulation model for vaginal hysterectomy, as described by Dr. Douglas Miyazaki.

Indigo carmine replacement? A recent issue in gynecologic surgery resulted when there was a national shortage of indigo carmine, which is commonly used to identify UO efflux at the time of cystoscopy. Dr. Katie Propst provided a solution: In the setting of planned cystoscopy, she found that preoperative phenazopyridine is an acceptable alternative and its use led to similar UO identification as with indigo carmine without an increase in complications.

Who should have a vaginal hysterectomy? Dr. Jennifer Schmitt from the Mayo Clinic gave another wonderful lecture describing a decision-tree algorithm for determining the ideal route of hysterectomy. According to a retrospective review of patients at their institution, vaginal hysterectomy was associated with lower infection rates, operative times, and costs.

The highlight of the morning was a very insightful Presidential Address by Dr. Andrew Walter! Not only is a he a very entertaining speaker but he also shed some light on 2 challenges that we currently face in the field. He eloquently stated that, “every woman who is a candidate for a vaginal hysterectomy should be able to get one and have it performed competently, and every woman who needs surgery should have one performed by someone who performs enough surgeries every year to competently perform the surgery.” He frequently alluded to the wise Dr. Mayo, who stated, “The best interest of the patient is the only interest to be considered…” Let’s never forget this as physicians!

Do you find removing the adnexa challenging when performing vaginal surgery? Check out the amazing idea from the Cleveland Clinic shown in video presentation 05! They clearly demonstrate using a single-site gel port or surgical glove placed in the vaginal incision to perform laparoscopy through the vagina. What a novel idea to avoid any abdominal incisions when there is a difficult vaginal adnexal surgery!

After the morning break, we watched a master vaginal surgeon perform a sacral colpopexy through the vaginal route. For details on this method, please reference video presentation 06.

An increase in health care costs is a huge problem in this country. Dr. Mary Van Meter suggested that one area in which we can improve is in the operating room (OR), specifically through decreasing the number of instruments sterilized. She found that only approximately 20% of the instruments on the operating field were actually used by the OR physician. It costs about $3 per instrument on the tray at Vanderbilt University, she said. When you think of the few number of instruments actually used, if we work to limit the number of instruments on the trays, we could cut significant costs. As reimbursement is getting increasingly linked to cost reduction, we all should be thinking about innovative ways to cut costs.

The oral posters were all excellent!

Dr. Ann Peters showed that, at a high-volume tertiary-care center, multimodal preoperative testing failed to definitively identify leiomyosarcoma (LMS), and the factors associated with increased LMS risk included older age, menopause, and presence of fibroids with concurrent pelvic, uterine, or adnexal mass.

Dr. Kevin Kremer found that preoperative antibiotics were used in 23% of cases in which they were not indicated, and the increased use rate was associated with entrance into the abdomen during surgery, the individual surgeon, and time under anesthesia.

Dr. Jessica Heft then stated that the incontinence rate after midurethral sling revision for vaginal exposure or pain was significantly higher with a partial as opposed to complete mesh excision.

Fecal incontinence treatment options

Dr. Peter Rosenblatt tackled the issue of “Innovation or experimentation: Where do we draw the line?” in the TeLinde lecture. He started by describing a condition for which he feels we do not have an acceptable amount of treatment options for patients: fecal incontinence. He described how he observed that the puborectalis muscle, not the external anal sphincter, was critical for fecal continence. He then devised a surgery that created a sling that would act as a synthetic puborectalis muscle. He had amazing success until one patient had a serious complication. Should you abandon a successful, innovative surgery due to one very severe complication, was the question. Where do we draw the line? I don’t have an answer…but I do know that we all need to thank our puborectalis muscle for our daily fecal continence!

This is not a new issue in medicine, explained Dr. Rosenblatt. From the beginning of medicine, there has been a balance between innovation and experimentation. So, what is innovation? It is when someone improves upon a device or process. In medicine, is it innovation or just variation? We frequently use medications and devices “off label,” and these techniques often improve our surgeries and outcomes for our patients. Innovation comes about through careful planning, a necessity created by an emergency, advances in technology, and through evolution of a procedure. Who are the innovators? YOU are! We are the ones who understand the unmet needs and the potential opportunities for improving medicine. Let’s all work together to innovate NOT experiment and make medicine better so our patients have the best care possible!

“New Frontiers in Gynecologic Surgery: Transgender Surgery and Functional Clitoroplasty after Female Genital Mutilation”

The final talk for the day was by the groundbreaking Dr. Marci Bowers, whose lecture started by reminding everyone that there is a difference between gender identity and gender expression. Once a person knows his or her gender identity they use gender expression to express this to the world, she pointed out. Dr. Bowers is a true innovator and is performing gender reassignment surgeries as well as female genital mutilation corrective surgeries. She has perfected a one-stage vaginoplasty, and she showed a video of the procedure, which results in a 90% chance of orgasm. She also noted that she is able to restore clitoral function in 100% of the cases of genital mutilation, and she performs these procedures free of charge.

She reminded us that all ObGyns need to be trained in treating transgender patients, and given the high rate of suicide among adolescent transgender individuals, we all need to work together to provide a supportive medical environment to help these patients. What a fascinating end to the day!

Some relaxation, and entertainment, amid the sun and outdoors

We then had the afternoon to compete in a golf tournament, explore the area on mountain bikes, or lounge by the pool. Regardless of the daytime activities, we all came back together for the great lip-synch competition! All 4 teams gave an impressive performance, but the team from Brown University went home with the win! Such an entertaining event! (Thanks to incoming SGS President Vivian Sung @wih_sung for the pic!)

4/11/16. DAY 2 AT SGS

Experts talk surgical innovations, complementary therapies, value-based payment, and much more at SGS day 2

Wake up and learn! The second day of the 42nd Annual Scientific Meeting of the Society of Gynecologic Surgeons began with a review of research posters at the Poster Session as the sun rose over the Palm Springs mountains. We then moved indoors for the scientific sessions.

In the first lecture, "Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease," Dr. Courtney Penn and colleagues reiterated that the postsurgical readmission rate is higher for patients undergoing abdominal hysterectomy compared with those who have a laparoscopic or vaginal hysterectomy. Similarly, Dr. Jennifer Schmitt and colleagues suggested that in a patient with a relative contraindication for vaginal hysterectomy, when this procedure is performed by an experienced surgeon there may not be increased complications. However, keep in mind that the study described—"A Comparison of Vaginal and Robotic Hysterectomy for Commonly Cited Relative Contraindications to Vaginal Hysterectomy"—was performed at the Mayo Clinic by expert, highly trained surgeons, and this fact may limit the generalizability of the study. As one audience member eloquently stated, it is important to remember that: "Just because it is feasible does not mean it is the correct procedure."

That yoga or barre class may be doing more good than you think! Lunge, bridge, and cat-into-cow movements may provide a greater degree of pelvic floor muscle unit recruitment than traditional Kegel exercises, according to a presentation by Dr. Bruce Crawford on Kegels versus specialized movement.

Perhaps those exercises should be recommended for surgeons as well. As Dr. Ruchira Singh pointed out, surgeons experience a high amount of musculoskeletal strain when performing vaginal procedures while sitting, regardless of the type of chair used during surgery. Dr. Singh and colleagues’ study, "Effect of Different Chairs on Work-Related Musculoskeletal Discomfort During Vaginal Surgery," found that while the round stool with a backrest and the Capisco chair were more comfortable, they did not eliminate the high risk for musculoskeletal strain, particularly in the head and neck.

Dr. Ann Peters and colleagues, from Magee-Womens Hospital of the University of Pittsburgh Medical Center, gave a fabulous video presentation on "Anatomic and Vascular Considerations in Laparoscopic Uterine Artery Ligation During Hysterectomy."

Need a novel treatment for interstitial cystitis/bladder pain syndrome? Consider mindfulness-based stress reduction. A randomized controlled study performed by Dr. Gregg Kanter and colleagues describes how this technique may help patients and could be considered a first-line therapy.

What is value-based payment and this new trend in reimbursement? And how does it apply to vaginal hysterectomy? Dr. Tina Groat addressed these issues in her keynote lecture. According to the American Congress of Obstetricians and Gynecologists, “Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy.” This is in opposition to what is actually being performed clinically. Dr. Groat explained that United Healthcare decided to incentivize physicians by requiring a prior authorization for all hysterectomies for benign disease. There is both a quality and cost benefit to performing a vaginal hysterectomy. Most insurance companies are moving away from a “fee for service” structure to performance-based payment. Change is always scary and, while I think the overall goal of moving toward the best care for our patients is a positive, this approach may create new challenges for the medical field. What do you think? Is performance-based payment beneficial? Or does it limit physicians and potentially force them to perform a procedure they do not feel as comfortable performing? Will this result in physicians rejecting certain patient populations? [Note from OBG MANAGEMENT: Let Dr. Collins know your thoughts through social media, or email OBG MANAGEMENT with a Letter to the Editor (rbarbieri@frontlinemedcom.com).]

The debate on the best route for hysterectomy continues: According to Dr. Carolyn Swenson and colleagues in their presentation, "Comparison of Robotic and Other Minimally Invasive Routes of Hysterectomy for Benign Indications," while there may be lower complications associated with robotic hysterectomy, the cost of performing a robotic hysterectomy is significantly higher than the cost of laparoscopic or vaginal hysterectomy, thus limiting its utility.

How can we teach a rare surgical procedure to learners? We channel our inner Martha Stewart and make a model out of a beef tongue and chicken. For about $8 a challenging and rare surgery can be taught to residents and medical students, according to the video presentation by Dr. Jana Illston and colleagues, titled "Modified Beef Tongue Model for Fourth-Degree Laceration Repair Simulation."

After the Day 2 lunch break, there was a rousing debate surrounding "Surgeons as Innovators—What Is the Patient Expecting?" Where do we draw the line between using an older more proven therapy as opposed to trying an innovative technology that may actually offer a potential benefit? Dr. Dennis Miller made a good point regarding innovation and pharmaceutical and device companies: If we ignore industry, we lose the ability to help with innovation and shape the future of medical treatments. Perhaps we should use the golden rule: If we would perform the surgery or use the device on ourselves, then we should perform it on our patient. Patients have a greater burden now, because there are more treatment options that they must choose among. Our job as physicians is to educate our patients and to guide them to innovative and evidence-based treatments.

Highlights from the afternoon oral poster session included a presentation by Dr. Caryn Russman that noted the high risk for recurrent urinary tract infection (UTI) after a mid-urethral sling procedure, which seems to be related to specific preoperative risk factors (such as a history of recurrent UTI). Dr. Tanya Hoke suggested that residents and attending physicians have inaccurate estimates of uterine weight, and an educational program may be necessary to improve these estimates. Finally, a study from Massachusetts General Hospital showed that a shorter stay in the hospital, ideally same-day surgery, resulted in a lower complication risk, lower number of emergency department visits, and a decreased readmission rate for patients undergoing urogynecology procedures.

The following recommendations were then suggested regarding vaginal hysterectomy:

• Preoperative prep with 4% chlorhexidine or povidine iodine
• Intracervical vasopressin injection to decrease blood loss
• Use of a pedicle-sealing device for pedicle ligation
• Vertical cuff closure is preferred to maximize vaginal length

Another important point made was that a prior cesarean delivery is not a contraindication to performing a vaginal hysterectomy.

Recommendations regarding recurrent UTI were also made, which include the recommendation for preoperative use of antibiotics to decrease the rate of UTI, with no benefit for a longer course of antibiotics.

News from the Fellows’ Pelvic Research Network

So much exciting research currently is ongoing with the FPRN! New project ideas include comparison of trimethoprim with methenamie for treatment of recurrent UTI; comparison of laparoscopic/robotic sacrocolpopexy with vaginal USLS for management of apical prolapse; a survey study examining surgeon preferences for timing of midurethral sling placement when performed at the time of pelvic organ prolapse (POP) repair; an assessment of the effect of a midurethal sling on overactive bladder in surgical repair in POP; and a study evaluating female pelvic reconstructive surgery in the setting of human immunodeficiency virus infection. It is so great to see the fellows working together to provide groundbreaking research!

Fun with stats

Learning statistics at the end of the day is never easy, but Dr. Matthew Barber did a fabulous job explaining this often-confusing topic. He reminded attendees that the key to learning statistics is repetition. One new recommendation he offered to enhance understanding is to use common language instead of numbers for P values. For example, instead of saying P <.001, use “is superior,” and instead of saying P = .3, use “seems not superior” or “inconclusive.”

A night to remember

The night ended with a wonderful awards ceremony and the president’s reception. Overall, day 2 was a very educational—and fun—day!

4/10/16. DAY 1 AT SGS

Postgrad courses address pain management and social media education

Mastering pelvic pain

With the beautiful Palm Springs, California, backdrop of mountains and palm trees, the 2016 meeting of the Society of Gynecologic Surgeons kicked off with 4 postgraduate courses. At the “Mastering Pelvic Pain: Strategies and Techniques for a Multimodal Approach” course, directed by Dr. Cara King, Dr. Matt Siedhoff explained the key components of the history and physical examination: Keep in mind that this generally is a multifactorial issue and may require a multidisciplinary approach, he told attendees. It is also important to make sure that the patient is fully prepared to combat the chronic pelvic pain (CPP) symptoms by focusing on the fundamentals, he said, including smoking, diet, exercise, weight loss, sleep, and relationship stress.

How is your posture? It turns out that something as simple as altering your posture can significantly affect pelvic floor control. Carol Sobeck, PT, demonstrated this importance with a simple group exercise that proved how the ability to contract the pelvic floor changes significantly with posture. Get to know your pelvic floor physical therapist—they are critical in helping with the treatment of CPP.

But what to do when physical therapy fails? Dr. Jennifer Gunter shed some light on this very difficult medical situation. One suggestion, she said, is to consider the possibility of a local presentation of a systemic issue and screen for the following: fibromyalgia, Ehlers-Danlos syndrome, statin use, and diabetes mellitus. Other treatment ideas include trigger point injections and onabotulinumtoxin A (Botox) therapy. A trigger point is a hypercontracted focus of muscle. To treat a trigger point, a needle must mechanically disrupt the trigger point to reduce the pelvic pain, and injection of local anesthetic is only used to help with postprocedure discomfort. Botox in my pelvis, you ask? Yes! The goal is to block presynaptic release of acetylcholine, which is very effective at reducing muscle spasm. 

Tackling endometriosis. Dr. King then described surgical techniques for endometriosis. She recommended that, for mild disease not in close proximity to vital structures, ablation is likely equivalent to excision. For deeply infiltrating endometriosis, or lesions in close proximity to vital structures, excision is more beneficial. Excision is always beneficial for pathologic diagnosis, she said. And she offered this tip for bladder endometriosis: place a stitch in the nodule to allow for counter traction. Here is another tip, for ovarian cystectomy: inject vasopressin (20 U in 60 mL) to help dissect the plane between the ovary and cyst wall, and consider presacral neurectomy for midline pain.

Dr. Frank Tu then explained that we should not think of it as the “terrible triad: endometriosis, irritable bowel syndrome, and interstitial cystsis,” but rather as a system out of balance. Both peripheral and central mechanisms are involved in the generation and maintenance of cross-organ sensitization, he pointed out, which may explain why patients receive multiple diagnoses that describe a myriad of complaints due to a lack of overall homeostasis.

While Dr. Alaa Abd-Elsayed described innovative nerve blocks for CPP, he emphasized that no one specific treatment will result in a complete resolution of symptoms.

Vaginal mesh placement and pain. Dr. Mario Castellanos gave a fabulous lecture describing the pain issues that surround vaginal mesh placement. Interestingly, he noted that many patients had pelvic pain prior to placement of vaginal mesh, and that pain likely only will worsen with mesh placement. Mesh may cause pain by causing inflammation, visceral injury, muscle injury, and nerve injury. While there are guidelines for where mesh should be placed for bladder slings (TVT and TOT) and for prolapse repair, studies show, he pointed out, that the mesh placement often disrupts several muscle groups and may directly injure a nerve.

Alternatives to the typical diagnoses for CPP. The morning ended with a lecture by Dr. Suzie As-Sanie, in which she reminded everyone to start with “gold standard” therapy but, if those fail, consider alternative diagnoses or a central pain disorder. She also suggested cognitive behavioral therapy for treatment of CPP. For patients who cannot afford cognitive behavioral therapy, there is a free online source at fibroguide.med.umich.edu. Other alternative treatment options include exercise, patient education, instruction on sleep hygiene, and neurostimulatory therapies.

Overall, all the speakers this morning agreed that CPP is rarely treated with one modality, and it is best treated with a multidisciplinary approach.

Let’s get social!

The afternoon was spent learning about ways to use social networking sites to educate our patients, in another postgraduate course on “Making Media Social,” presented by the SGS Social Media Committee. Given that a recent survey demonstrated that 74.1% of women have some type of social networking account, it can be a very useful source for medical information for patients. If you have any questions about what is appropriate on social media, check out ACOG committee opinion 622.

Here are some tips that I learned:

Facebook:

• Keep your private Facebook page private and create a separate professional Facebook page
• Adjust your login setting so only administrators can post on your professional page
• Adjust settings so your professional profile cannot be “tagged”
• If a patient contacts your personal page, direct them to your professional page
• Do not give medical advice since Facebook is not digitally encrypted

Twitter:

• “Short bursts of inconsequential information”
• Follow societies, medical centers, and medical journals

LinkedIn:

• It provides a great way to find jobs, people, and business opportunities that are recommended by someone in your contact group
• It is specifically there to help you grow your business and show people who you are and where you have come from

Doximity:
Before we get to tips, first, what is it? Well, Doximity is basically a “LinkedIn” for physicians. It is “a way to find relevant specialists for patients; a rolodex; an email and text service; and a virtual lounge.” It is currently transforming from social network into a ‘platform.’ Now more than 1,000 hospitals and health systems are part of Doximity. Tips:

• There is a secure message option, which is HIPAA compliant
• Provides a way for residents and fellows to understand possible future places of employment
• It is a great way to find someone to refer patients to in an unfamiliar location

Vimeo:

• A benefit over YouTube is the lack of advertisements
• Check out the SGS video archives!
• You also can set privacy settings and embedding stats

Fifty-nine percent of US adults have looked online for health information in the past year. Therefore, it is important for physicians to get good information out for people to see!

A relaxing day’s end

The night ended with a beautiful poolside reception! I can’t wait to see what day 2 will bring!

4/13/16. DAY 4 AT SGS

A jam-packed day of sessions, posters, awards, and clinical updates

Our last educational day was kicked off by a fascinating lecture by Dr. Amy Park on the “Genetic Determinants of Pelvic Organ Prolapse in Women of European American Descent: The Women’s Health Initiative.” Dr. Park and her colleagues found that there is evidence of phenotypic and genotypic heterogeneity in patients with pelvic organ prolapse, and there were 4 genetic loci identified that correlated with prolapse. Any uterine prolapse was associated with a genome-wide significant intergenic variant on chromosome 13, cystocele was associated with LOXL2, and all prolapse was associated with BMP.

Surmounting surgical site infection

Dr. Sarah Andiman then gave a lecture on the effects of a perioperative bundle and offered timely feedback for surgical site infection (SSI) prevention in hysterectomy. We all know that wound infections are a major morbidity associated with surgery, and Dr. Andiman’s group at Yale found that, by implementing this prevention program, the surgical site infection decreased 52.8%. Another suggestion from the audience was to have all patients use chlorhexidine wipes the night before and morning of a surgery to decrease wound infection. Similarly, Dr. Ali Bazzi gave a lecture on “Chlorhexidine-Alcohol Compared with Povidone-Iodine for Surgical-Site Antisepsis after Abdominal Hysterectomy.” The chlorhexidine was associated with 30% lower odds of SSI compared with povidone-iodine, even though this group had several medical comorbidities and risk factors known for SSIs.

Oral poster presenters make several interesting points

Dr. Christopher Ripperda from UT Southwestern Medical Center in Dallas, Texas, found that medical comorbidities and the presence of detrusor overactivity and PVR are predictors of early postoperative voiding dysfunction following a midurethral sling placement. Dr. Nabila Noor then described a fabulous surgical alternative to the use of morcellation to remove the uterus after a supracervical hysterectomy. She described the technique for performing a posterior colpotomy and stated that patients who had a surgery performed at her institution using this technique did not experience increased postoperative pain or longer postoperative stay.

Dr. Jennifer Thompson then shed some light on a very important question related to the Sunshine Act: Are physicians including all of their disclosures when they submit articles to a conference? When the physicians who submitted an abstract to the Society of Gynecologic Surgeons (SGS) in 2015 were searched on the Centers for Medicare and Medicaid Services (CMS) website, 62% of them had incomplete disclosures, with a total of nondisclosed CMS transactions equaling $1.3 million. We can do better!

Status update: The FPRN and passing of the torch

Congratulations to Dr. Kristin Jacobs, the new Fellows’ Pelvic Research Network (FPRN) Chair! The morning session ended with an innovative video from Dr. Janet Li and colleagues on the “Use of Suprapubic Carter-Thomason Needle to Assist in Cystoscopic Excision of Intravesical Foreign Object.”

The winner of the Distinguished Surgeon Award was given to Dr. Javier Magrina, and the SGS gavel was passed on to Dr. Vivian Sung! Congratulations!

Dr. Stephanie Pickett kicked off the eighth scientific session with a study entitled, “Comparing Methods of NSAID Delivery for Postoperative Pain.” When she and her colleagues compared IV toradol to IV ibuprofen for postoperative pain control after urogynecologic surgery, they found that patients experienced similar rates of pain control and satisfaction regardless of the type of analgesia.

Why are patients being readmitted after gynecologic oncology surgery?

The answer to this question is important as readmission rates are being considered for physician and hospital reimbursement. Dr. MaryAnn Wilbur and colleagues looked at the rates of unplanned 30-day readmission in gyn oncology patients. The patients who were readmitted had the following characteristics: ovarian cancer, creation of ostomy, Charleston score >5, language barrier, and positive discharge screen. Gastrointestinal disturbance and SSI were the most common reasons for readmission, and the total readmission-related costs for these patients was about $4.5 million.

Considering tissue extraction, surgical complications, and cognitive impairment

We then had 3 fabulous oral poster presentations. Dr. Emily Von Bargen and colleagues presented a study entitled, “Prevalence of Occult Pre-malignant or Malignant Pathology at the time of Uterine Morcellation for Benign Disease.” They performed a multicenter retrospective cohort study and found that 1.2% of women had a premalignant or malignant uterine pathology after surgery, with a prevalence of 0.66% of occult malignancy. She was unable to identify risk factors for those patients who had a premalignant or malignant pathology. Overall she found a low prevalence of premalignant or malignant uterine pathology when uterine morcellation was performed for benign disease.

Dr. Alix Leader-Cramer from Northwestern University pointed out “risk factors for a 30-day perioperative complications for total vaginal hysterectomy,” including chronic steroid use, higher ASA classification, current smoking status, diabetes, and lower preoperative serum albumin and sodium levels. Adnexectomy and resident participation were also associated with increased perioperative complications. About 9.5% of patients had a perioperative complication in the study population studied.

Finally, Dr. Elisa Trowbridge pointed out in her talk, on “Cognitive Impairment among Elderly Urogynecologic Patients,” that cognitive impairment is very prevalent among such women aged older than 75 years, and the Mini-Cog is a feasible screening tool.

What a way to end an AMAZING conference!

The conference ended with a fabulous video presentation by Dr. Andrea Benton, entitled “Surgical Approaches to the Management of Bladder and Ureteral Endometriosis.” Overall, the themes of this year’s SGS conference were to:

• emphasize the importance of performing a vaginal hysterectomy when feasible
• continue to strive to balance innovation with experimentation
• ensure that patients are being operated on by surgeons who are competent and frequently performing the indicated procedure.

Thank you to everyone who shared their research to educate the attendees at the conference! I can’t wait until next year!

4/12/16. DAY 3 AT SGS

Vaginal hysterectomy, fecal incontinence, transgender surgery amid tackled topics in Palm Springs

I could get used to sipping my coffee with the sunny background here in Palm Springs! It was a beautiful morning to learn.

We started the day with breakfast and a fabulous lecture on the inferior gluteal neurovascular anatomy in female cadavers, and an insightful lecture by Dr. Bhumy Dave, who brought up concerns about tracking for obstetrics and gynecology residency programs. She specifically highlighted the need for more experience with vaginal hysterectomies for residents who are going to be in a subspecialty that performs vaginal surgery. As the number of hysterectomies, specifically vaginal hysterectomies, declines every year, we need to make sure we are adequately training the physicians who will be performing this procedure in the future. One solution is to have residents join a track their 4th year of residency, after their future career path has been established. Another possible solution would be to increase use of a simulation model for vaginal hysterectomy, as described by Dr. Douglas Miyazaki.

Indigo carmine replacement? A recent issue in gynecologic surgery resulted when there was a national shortage of indigo carmine, which is commonly used to identify UO efflux at the time of cystoscopy. Dr. Katie Propst provided a solution: In the setting of planned cystoscopy, she found that preoperative phenazopyridine is an acceptable alternative and its use led to similar UO identification as with indigo carmine without an increase in complications.

Who should have a vaginal hysterectomy? Dr. Jennifer Schmitt from the Mayo Clinic gave another wonderful lecture describing a decision-tree algorithm for determining the ideal route of hysterectomy. According to a retrospective review of patients at their institution, vaginal hysterectomy was associated with lower infection rates, operative times, and costs.

The highlight of the morning was a very insightful Presidential Address by Dr. Andrew Walter! Not only is a he a very entertaining speaker but he also shed some light on 2 challenges that we currently face in the field. He eloquently stated that, “every woman who is a candidate for a vaginal hysterectomy should be able to get one and have it performed competently, and every woman who needs surgery should have one performed by someone who performs enough surgeries every year to competently perform the surgery.” He frequently alluded to the wise Dr. Mayo, who stated, “The best interest of the patient is the only interest to be considered…” Let’s never forget this as physicians!

Do you find removing the adnexa challenging when performing vaginal surgery? Check out the amazing idea from the Cleveland Clinic shown in video presentation 05! They clearly demonstrate using a single-site gel port or surgical glove placed in the vaginal incision to perform laparoscopy through the vagina. What a novel idea to avoid any abdominal incisions when there is a difficult vaginal adnexal surgery!

After the morning break, we watched a master vaginal surgeon perform a sacral colpopexy through the vaginal route. For details on this method, please reference video presentation 06.

An increase in health care costs is a huge problem in this country. Dr. Mary Van Meter suggested that one area in which we can improve is in the operating room (OR), specifically through decreasing the number of instruments sterilized. She found that only approximately 20% of the instruments on the operating field were actually used by the OR physician. It costs about $3 per instrument on the tray at Vanderbilt University, she said. When you think of the few number of instruments actually used, if we work to limit the number of instruments on the trays, we could cut significant costs. As reimbursement is getting increasingly linked to cost reduction, we all should be thinking about innovative ways to cut costs.

The oral posters were all excellent!

Dr. Ann Peters showed that, at a high-volume tertiary-care center, multimodal preoperative testing failed to definitively identify leiomyosarcoma (LMS), and the factors associated with increased LMS risk included older age, menopause, and presence of fibroids with concurrent pelvic, uterine, or adnexal mass.

Dr. Kevin Kremer found that preoperative antibiotics were used in 23% of cases in which they were not indicated, and the increased use rate was associated with entrance into the abdomen during surgery, the individual surgeon, and time under anesthesia.

Dr. Jessica Heft then stated that the incontinence rate after midurethral sling revision for vaginal exposure or pain was significantly higher with a partial as opposed to complete mesh excision.

Fecal incontinence treatment options

Dr. Peter Rosenblatt tackled the issue of “Innovation or experimentation: Where do we draw the line?” in the TeLinde lecture. He started by describing a condition for which he feels we do not have an acceptable amount of treatment options for patients: fecal incontinence. He described how he observed that the puborectalis muscle, not the external anal sphincter, was critical for fecal continence. He then devised a surgery that created a sling that would act as a synthetic puborectalis muscle. He had amazing success until one patient had a serious complication. Should you abandon a successful, innovative surgery due to one very severe complication, was the question. Where do we draw the line? I don’t have an answer…but I do know that we all need to thank our puborectalis muscle for our daily fecal continence!

This is not a new issue in medicine, explained Dr. Rosenblatt. From the beginning of medicine, there has been a balance between innovation and experimentation. So, what is innovation? It is when someone improves upon a device or process. In medicine, is it innovation or just variation? We frequently use medications and devices “off label,” and these techniques often improve our surgeries and outcomes for our patients. Innovation comes about through careful planning, a necessity created by an emergency, advances in technology, and through evolution of a procedure. Who are the innovators? YOU are! We are the ones who understand the unmet needs and the potential opportunities for improving medicine. Let’s all work together to innovate NOT experiment and make medicine better so our patients have the best care possible!

“New Frontiers in Gynecologic Surgery: Transgender Surgery and Functional Clitoroplasty after Female Genital Mutilation”

The final talk for the day was by the groundbreaking Dr. Marci Bowers, whose lecture started by reminding everyone that there is a difference between gender identity and gender expression. Once a person knows his or her gender identity they use gender expression to express this to the world, she pointed out. Dr. Bowers is a true innovator and is performing gender reassignment surgeries as well as female genital mutilation corrective surgeries. She has perfected a one-stage vaginoplasty, and she showed a video of the procedure, which results in a 90% chance of orgasm. She also noted that she is able to restore clitoral function in 100% of the cases of genital mutilation, and she performs these procedures free of charge.

She reminded us that all ObGyns need to be trained in treating transgender patients, and given the high rate of suicide among adolescent transgender individuals, we all need to work together to provide a supportive medical environment to help these patients. What a fascinating end to the day!

Some relaxation, and entertainment, amid the sun and outdoors

We then had the afternoon to compete in a golf tournament, explore the area on mountain bikes, or lounge by the pool. Regardless of the daytime activities, we all came back together for the great lip-synch competition! All 4 teams gave an impressive performance, but the team from Brown University went home with the win! Such an entertaining event! (Thanks to incoming SGS President Vivian Sung @wih_sung for the pic!)

4/11/16. DAY 2 AT SGS

Experts talk surgical innovations, complementary therapies, value-based payment, and much more at SGS day 2

Wake up and learn! The second day of the 42nd Annual Scientific Meeting of the Society of Gynecologic Surgeons began with a review of research posters at the Poster Session as the sun rose over the Palm Springs mountains. We then moved indoors for the scientific sessions.

In the first lecture, "Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease," Dr. Courtney Penn and colleagues reiterated that the postsurgical readmission rate is higher for patients undergoing abdominal hysterectomy compared with those who have a laparoscopic or vaginal hysterectomy. Similarly, Dr. Jennifer Schmitt and colleagues suggested that in a patient with a relative contraindication for vaginal hysterectomy, when this procedure is performed by an experienced surgeon there may not be increased complications. However, keep in mind that the study described—"A Comparison of Vaginal and Robotic Hysterectomy for Commonly Cited Relative Contraindications to Vaginal Hysterectomy"—was performed at the Mayo Clinic by expert, highly trained surgeons, and this fact may limit the generalizability of the study. As one audience member eloquently stated, it is important to remember that: "Just because it is feasible does not mean it is the correct procedure."

That yoga or barre class may be doing more good than you think! Lunge, bridge, and cat-into-cow movements may provide a greater degree of pelvic floor muscle unit recruitment than traditional Kegel exercises, according to a presentation by Dr. Bruce Crawford on Kegels versus specialized movement.

Perhaps those exercises should be recommended for surgeons as well. As Dr. Ruchira Singh pointed out, surgeons experience a high amount of musculoskeletal strain when performing vaginal procedures while sitting, regardless of the type of chair used during surgery. Dr. Singh and colleagues’ study, "Effect of Different Chairs on Work-Related Musculoskeletal Discomfort During Vaginal Surgery," found that while the round stool with a backrest and the Capisco chair were more comfortable, they did not eliminate the high risk for musculoskeletal strain, particularly in the head and neck.

Dr. Ann Peters and colleagues, from Magee-Womens Hospital of the University of Pittsburgh Medical Center, gave a fabulous video presentation on "Anatomic and Vascular Considerations in Laparoscopic Uterine Artery Ligation During Hysterectomy."

Need a novel treatment for interstitial cystitis/bladder pain syndrome? Consider mindfulness-based stress reduction. A randomized controlled study performed by Dr. Gregg Kanter and colleagues describes how this technique may help patients and could be considered a first-line therapy.

What is value-based payment and this new trend in reimbursement? And how does it apply to vaginal hysterectomy? Dr. Tina Groat addressed these issues in her keynote lecture. According to the American Congress of Obstetricians and Gynecologists, “Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy.” This is in opposition to what is actually being performed clinically. Dr. Groat explained that United Healthcare decided to incentivize physicians by requiring a prior authorization for all hysterectomies for benign disease. There is both a quality and cost benefit to performing a vaginal hysterectomy. Most insurance companies are moving away from a “fee for service” structure to performance-based payment. Change is always scary and, while I think the overall goal of moving toward the best care for our patients is a positive, this approach may create new challenges for the medical field. What do you think? Is performance-based payment beneficial? Or does it limit physicians and potentially force them to perform a procedure they do not feel as comfortable performing? Will this result in physicians rejecting certain patient populations? [Note from OBG MANAGEMENT: Let Dr. Collins know your thoughts through social media, or email OBG MANAGEMENT with a Letter to the Editor (rbarbieri@frontlinemedcom.com).]

The debate on the best route for hysterectomy continues: According to Dr. Carolyn Swenson and colleagues in their presentation, "Comparison of Robotic and Other Minimally Invasive Routes of Hysterectomy for Benign Indications," while there may be lower complications associated with robotic hysterectomy, the cost of performing a robotic hysterectomy is significantly higher than the cost of laparoscopic or vaginal hysterectomy, thus limiting its utility.

How can we teach a rare surgical procedure to learners? We channel our inner Martha Stewart and make a model out of a beef tongue and chicken. For about $8 a challenging and rare surgery can be taught to residents and medical students, according to the video presentation by Dr. Jana Illston and colleagues, titled "Modified Beef Tongue Model for Fourth-Degree Laceration Repair Simulation."

After the Day 2 lunch break, there was a rousing debate surrounding "Surgeons as Innovators—What Is the Patient Expecting?" Where do we draw the line between using an older more proven therapy as opposed to trying an innovative technology that may actually offer a potential benefit? Dr. Dennis Miller made a good point regarding innovation and pharmaceutical and device companies: If we ignore industry, we lose the ability to help with innovation and shape the future of medical treatments. Perhaps we should use the golden rule: If we would perform the surgery or use the device on ourselves, then we should perform it on our patient. Patients have a greater burden now, because there are more treatment options that they must choose among. Our job as physicians is to educate our patients and to guide them to innovative and evidence-based treatments.

Highlights from the afternoon oral poster session included a presentation by Dr. Caryn Russman that noted the high risk for recurrent urinary tract infection (UTI) after a mid-urethral sling procedure, which seems to be related to specific preoperative risk factors (such as a history of recurrent UTI). Dr. Tanya Hoke suggested that residents and attending physicians have inaccurate estimates of uterine weight, and an educational program may be necessary to improve these estimates. Finally, a study from Massachusetts General Hospital showed that a shorter stay in the hospital, ideally same-day surgery, resulted in a lower complication risk, lower number of emergency department visits, and a decreased readmission rate for patients undergoing urogynecology procedures.

The following recommendations were then suggested regarding vaginal hysterectomy:

• Preoperative prep with 4% chlorhexidine or povidine iodine
• Intracervical vasopressin injection to decrease blood loss
• Use of a pedicle-sealing device for pedicle ligation
• Vertical cuff closure is preferred to maximize vaginal length

Another important point made was that a prior cesarean delivery is not a contraindication to performing a vaginal hysterectomy.

Recommendations regarding recurrent UTI were also made, which include the recommendation for preoperative use of antibiotics to decrease the rate of UTI, with no benefit for a longer course of antibiotics.

News from the Fellows’ Pelvic Research Network

So much exciting research currently is ongoing with the FPRN! New project ideas include comparison of trimethoprim with methenamie for treatment of recurrent UTI; comparison of laparoscopic/robotic sacrocolpopexy with vaginal USLS for management of apical prolapse; a survey study examining surgeon preferences for timing of midurethral sling placement when performed at the time of pelvic organ prolapse (POP) repair; an assessment of the effect of a midurethal sling on overactive bladder in surgical repair in POP; and a study evaluating female pelvic reconstructive surgery in the setting of human immunodeficiency virus infection. It is so great to see the fellows working together to provide groundbreaking research!

Fun with stats

Learning statistics at the end of the day is never easy, but Dr. Matthew Barber did a fabulous job explaining this often-confusing topic. He reminded attendees that the key to learning statistics is repetition. One new recommendation he offered to enhance understanding is to use common language instead of numbers for P values. For example, instead of saying P <.001, use “is superior,” and instead of saying P = .3, use “seems not superior” or “inconclusive.”

A night to remember

The night ended with a wonderful awards ceremony and the president’s reception. Overall, day 2 was a very educational—and fun—day!

4/10/16. DAY 1 AT SGS

Postgrad courses address pain management and social media education

Mastering pelvic pain

With the beautiful Palm Springs, California, backdrop of mountains and palm trees, the 2016 meeting of the Society of Gynecologic Surgeons kicked off with 4 postgraduate courses. At the “Mastering Pelvic Pain: Strategies and Techniques for a Multimodal Approach” course, directed by Dr. Cara King, Dr. Matt Siedhoff explained the key components of the history and physical examination: Keep in mind that this generally is a multifactorial issue and may require a multidisciplinary approach, he told attendees. It is also important to make sure that the patient is fully prepared to combat the chronic pelvic pain (CPP) symptoms by focusing on the fundamentals, he said, including smoking, diet, exercise, weight loss, sleep, and relationship stress.

How is your posture? It turns out that something as simple as altering your posture can significantly affect pelvic floor control. Carol Sobeck, PT, demonstrated this importance with a simple group exercise that proved how the ability to contract the pelvic floor changes significantly with posture. Get to know your pelvic floor physical therapist—they are critical in helping with the treatment of CPP.

But what to do when physical therapy fails? Dr. Jennifer Gunter shed some light on this very difficult medical situation. One suggestion, she said, is to consider the possibility of a local presentation of a systemic issue and screen for the following: fibromyalgia, Ehlers-Danlos syndrome, statin use, and diabetes mellitus. Other treatment ideas include trigger point injections and onabotulinumtoxin A (Botox) therapy. A trigger point is a hypercontracted focus of muscle. To treat a trigger point, a needle must mechanically disrupt the trigger point to reduce the pelvic pain, and injection of local anesthetic is only used to help with postprocedure discomfort. Botox in my pelvis, you ask? Yes! The goal is to block presynaptic release of acetylcholine, which is very effective at reducing muscle spasm. 

Tackling endometriosis. Dr. King then described surgical techniques for endometriosis. She recommended that, for mild disease not in close proximity to vital structures, ablation is likely equivalent to excision. For deeply infiltrating endometriosis, or lesions in close proximity to vital structures, excision is more beneficial. Excision is always beneficial for pathologic diagnosis, she said. And she offered this tip for bladder endometriosis: place a stitch in the nodule to allow for counter traction. Here is another tip, for ovarian cystectomy: inject vasopressin (20 U in 60 mL) to help dissect the plane between the ovary and cyst wall, and consider presacral neurectomy for midline pain.

Dr. Frank Tu then explained that we should not think of it as the “terrible triad: endometriosis, irritable bowel syndrome, and interstitial cystsis,” but rather as a system out of balance. Both peripheral and central mechanisms are involved in the generation and maintenance of cross-organ sensitization, he pointed out, which may explain why patients receive multiple diagnoses that describe a myriad of complaints due to a lack of overall homeostasis.

While Dr. Alaa Abd-Elsayed described innovative nerve blocks for CPP, he emphasized that no one specific treatment will result in a complete resolution of symptoms.

Vaginal mesh placement and pain. Dr. Mario Castellanos gave a fabulous lecture describing the pain issues that surround vaginal mesh placement. Interestingly, he noted that many patients had pelvic pain prior to placement of vaginal mesh, and that pain likely only will worsen with mesh placement. Mesh may cause pain by causing inflammation, visceral injury, muscle injury, and nerve injury. While there are guidelines for where mesh should be placed for bladder slings (TVT and TOT) and for prolapse repair, studies show, he pointed out, that the mesh placement often disrupts several muscle groups and may directly injure a nerve.

Alternatives to the typical diagnoses for CPP. The morning ended with a lecture by Dr. Suzie As-Sanie, in which she reminded everyone to start with “gold standard” therapy but, if those fail, consider alternative diagnoses or a central pain disorder. She also suggested cognitive behavioral therapy for treatment of CPP. For patients who cannot afford cognitive behavioral therapy, there is a free online source at fibroguide.med.umich.edu. Other alternative treatment options include exercise, patient education, instruction on sleep hygiene, and neurostimulatory therapies.

Overall, all the speakers this morning agreed that CPP is rarely treated with one modality, and it is best treated with a multidisciplinary approach.

Let’s get social!

The afternoon was spent learning about ways to use social networking sites to educate our patients, in another postgraduate course on “Making Media Social,” presented by the SGS Social Media Committee. Given that a recent survey demonstrated that 74.1% of women have some type of social networking account, it can be a very useful source for medical information for patients. If you have any questions about what is appropriate on social media, check out ACOG committee opinion 622.

Here are some tips that I learned:

Facebook:

• Keep your private Facebook page private and create a separate professional Facebook page
• Adjust your login setting so only administrators can post on your professional page
• Adjust settings so your professional profile cannot be “tagged”
• If a patient contacts your personal page, direct them to your professional page
• Do not give medical advice since Facebook is not digitally encrypted

Twitter:

• “Short bursts of inconsequential information”
• Follow societies, medical centers, and medical journals

LinkedIn:

• It provides a great way to find jobs, people, and business opportunities that are recommended by someone in your contact group
• It is specifically there to help you grow your business and show people who you are and where you have come from

Doximity:
Before we get to tips, first, what is it? Well, Doximity is basically a “LinkedIn” for physicians. It is “a way to find relevant specialists for patients; a rolodex; an email and text service; and a virtual lounge.” It is currently transforming from social network into a ‘platform.’ Now more than 1,000 hospitals and health systems are part of Doximity. Tips:

• There is a secure message option, which is HIPAA compliant
• Provides a way for residents and fellows to understand possible future places of employment
• It is a great way to find someone to refer patients to in an unfamiliar location

Vimeo:

• A benefit over YouTube is the lack of advertisements
• Check out the SGS video archives!
• You also can set privacy settings and embedding stats

Fifty-nine percent of US adults have looked online for health information in the past year. Therefore, it is important for physicians to get good information out for people to see!

A relaxing day’s end

The night ended with a beautiful poolside reception! I can’t wait to see what day 2 will bring!

4/13/16. DAY 4 AT SGS

A jam-packed day of sessions, posters, awards, and clinical updates

Our last educational day was kicked off by a fascinating lecture by Dr. Amy Park on the “Genetic Determinants of Pelvic Organ Prolapse in Women of European American Descent: The Women’s Health Initiative.” Dr. Park and her colleagues found that there is evidence of phenotypic and genotypic heterogeneity in patients with pelvic organ prolapse, and there were 4 genetic loci identified that correlated with prolapse. Any uterine prolapse was associated with a genome-wide significant intergenic variant on chromosome 13, cystocele was associated with LOXL2, and all prolapse was associated with BMP.

Surmounting surgical site infection

Dr. Sarah Andiman then gave a lecture on the effects of a perioperative bundle and offered timely feedback for surgical site infection (SSI) prevention in hysterectomy. We all know that wound infections are a major morbidity associated with surgery, and Dr. Andiman’s group at Yale found that, by implementing this prevention program, the surgical site infection decreased 52.8%. Another suggestion from the audience was to have all patients use chlorhexidine wipes the night before and morning of a surgery to decrease wound infection. Similarly, Dr. Ali Bazzi gave a lecture on “Chlorhexidine-Alcohol Compared with Povidone-Iodine for Surgical-Site Antisepsis after Abdominal Hysterectomy.” The chlorhexidine was associated with 30% lower odds of SSI compared with povidone-iodine, even though this group had several medical comorbidities and risk factors known for SSIs.

Oral poster presenters make several interesting points

Dr. Christopher Ripperda from UT Southwestern Medical Center in Dallas, Texas, found that medical comorbidities and the presence of detrusor overactivity and PVR are predictors of early postoperative voiding dysfunction following a midurethral sling placement. Dr. Nabila Noor then described a fabulous surgical alternative to the use of morcellation to remove the uterus after a supracervical hysterectomy. She described the technique for performing a posterior colpotomy and stated that patients who had a surgery performed at her institution using this technique did not experience increased postoperative pain or longer postoperative stay.

Dr. Jennifer Thompson then shed some light on a very important question related to the Sunshine Act: Are physicians including all of their disclosures when they submit articles to a conference? When the physicians who submitted an abstract to the Society of Gynecologic Surgeons (SGS) in 2015 were searched on the Centers for Medicare and Medicaid Services (CMS) website, 62% of them had incomplete disclosures, with a total of nondisclosed CMS transactions equaling $1.3 million. We can do better!

Status update: The FPRN and passing of the torch

Congratulations to Dr. Kristin Jacobs, the new Fellows’ Pelvic Research Network (FPRN) Chair! The morning session ended with an innovative video from Dr. Janet Li and colleagues on the “Use of Suprapubic Carter-Thomason Needle to Assist in Cystoscopic Excision of Intravesical Foreign Object.”

The winner of the Distinguished Surgeon Award was given to Dr. Javier Magrina, and the SGS gavel was passed on to Dr. Vivian Sung! Congratulations!

Dr. Stephanie Pickett kicked off the eighth scientific session with a study entitled, “Comparing Methods of NSAID Delivery for Postoperative Pain.” When she and her colleagues compared IV toradol to IV ibuprofen for postoperative pain control after urogynecologic surgery, they found that patients experienced similar rates of pain control and satisfaction regardless of the type of analgesia.

Why are patients being readmitted after gynecologic oncology surgery?

The answer to this question is important as readmission rates are being considered for physician and hospital reimbursement. Dr. MaryAnn Wilbur and colleagues looked at the rates of unplanned 30-day readmission in gyn oncology patients. The patients who were readmitted had the following characteristics: ovarian cancer, creation of ostomy, Charleston score >5, language barrier, and positive discharge screen. Gastrointestinal disturbance and SSI were the most common reasons for readmission, and the total readmission-related costs for these patients was about $4.5 million.

Considering tissue extraction, surgical complications, and cognitive impairment

We then had 3 fabulous oral poster presentations. Dr. Emily Von Bargen and colleagues presented a study entitled, “Prevalence of Occult Pre-malignant or Malignant Pathology at the time of Uterine Morcellation for Benign Disease.” They performed a multicenter retrospective cohort study and found that 1.2% of women had a premalignant or malignant uterine pathology after surgery, with a prevalence of 0.66% of occult malignancy. She was unable to identify risk factors for those patients who had a premalignant or malignant pathology. Overall she found a low prevalence of premalignant or malignant uterine pathology when uterine morcellation was performed for benign disease.

Dr. Alix Leader-Cramer from Northwestern University pointed out “risk factors for a 30-day perioperative complications for total vaginal hysterectomy,” including chronic steroid use, higher ASA classification, current smoking status, diabetes, and lower preoperative serum albumin and sodium levels. Adnexectomy and resident participation were also associated with increased perioperative complications. About 9.5% of patients had a perioperative complication in the study population studied.

Finally, Dr. Elisa Trowbridge pointed out in her talk, on “Cognitive Impairment among Elderly Urogynecologic Patients,” that cognitive impairment is very prevalent among such women aged older than 75 years, and the Mini-Cog is a feasible screening tool.

What a way to end an AMAZING conference!

The conference ended with a fabulous video presentation by Dr. Andrea Benton, entitled “Surgical Approaches to the Management of Bladder and Ureteral Endometriosis.” Overall, the themes of this year’s SGS conference were to:

• emphasize the importance of performing a vaginal hysterectomy when feasible
• continue to strive to balance innovation with experimentation
• ensure that patients are being operated on by surgeons who are competent and frequently performing the indicated procedure.

Thank you to everyone who shared their research to educate the attendees at the conference! I can’t wait until next year!

4/12/16. DAY 3 AT SGS

Vaginal hysterectomy, fecal incontinence, transgender surgery amid tackled topics in Palm Springs

I could get used to sipping my coffee with the sunny background here in Palm Springs! It was a beautiful morning to learn.

We started the day with breakfast and a fabulous lecture on the inferior gluteal neurovascular anatomy in female cadavers, and an insightful lecture by Dr. Bhumy Dave, who brought up concerns about tracking for obstetrics and gynecology residency programs. She specifically highlighted the need for more experience with vaginal hysterectomies for residents who are going to be in a subspecialty that performs vaginal surgery. As the number of hysterectomies, specifically vaginal hysterectomies, declines every year, we need to make sure we are adequately training the physicians who will be performing this procedure in the future. One solution is to have residents join a track their 4th year of residency, after their future career path has been established. Another possible solution would be to increase use of a simulation model for vaginal hysterectomy, as described by Dr. Douglas Miyazaki.

Indigo carmine replacement? A recent issue in gynecologic surgery resulted when there was a national shortage of indigo carmine, which is commonly used to identify UO efflux at the time of cystoscopy. Dr. Katie Propst provided a solution: In the setting of planned cystoscopy, she found that preoperative phenazopyridine is an acceptable alternative and its use led to similar UO identification as with indigo carmine without an increase in complications.

Who should have a vaginal hysterectomy? Dr. Jennifer Schmitt from the Mayo Clinic gave another wonderful lecture describing a decision-tree algorithm for determining the ideal route of hysterectomy. According to a retrospective review of patients at their institution, vaginal hysterectomy was associated with lower infection rates, operative times, and costs.

The highlight of the morning was a very insightful Presidential Address by Dr. Andrew Walter! Not only is a he a very entertaining speaker but he also shed some light on 2 challenges that we currently face in the field. He eloquently stated that, “every woman who is a candidate for a vaginal hysterectomy should be able to get one and have it performed competently, and every woman who needs surgery should have one performed by someone who performs enough surgeries every year to competently perform the surgery.” He frequently alluded to the wise Dr. Mayo, who stated, “The best interest of the patient is the only interest to be considered…” Let’s never forget this as physicians!

Do you find removing the adnexa challenging when performing vaginal surgery? Check out the amazing idea from the Cleveland Clinic shown in video presentation 05! They clearly demonstrate using a single-site gel port or surgical glove placed in the vaginal incision to perform laparoscopy through the vagina. What a novel idea to avoid any abdominal incisions when there is a difficult vaginal adnexal surgery!

After the morning break, we watched a master vaginal surgeon perform a sacral colpopexy through the vaginal route. For details on this method, please reference video presentation 06.

An increase in health care costs is a huge problem in this country. Dr. Mary Van Meter suggested that one area in which we can improve is in the operating room (OR), specifically through decreasing the number of instruments sterilized. She found that only approximately 20% of the instruments on the operating field were actually used by the OR physician. It costs about $3 per instrument on the tray at Vanderbilt University, she said. When you think of the few number of instruments actually used, if we work to limit the number of instruments on the trays, we could cut significant costs. As reimbursement is getting increasingly linked to cost reduction, we all should be thinking about innovative ways to cut costs.

The oral posters were all excellent!

Dr. Ann Peters showed that, at a high-volume tertiary-care center, multimodal preoperative testing failed to definitively identify leiomyosarcoma (LMS), and the factors associated with increased LMS risk included older age, menopause, and presence of fibroids with concurrent pelvic, uterine, or adnexal mass.

Dr. Kevin Kremer found that preoperative antibiotics were used in 23% of cases in which they were not indicated, and the increased use rate was associated with entrance into the abdomen during surgery, the individual surgeon, and time under anesthesia.

Dr. Jessica Heft then stated that the incontinence rate after midurethral sling revision for vaginal exposure or pain was significantly higher with a partial as opposed to complete mesh excision.

Fecal incontinence treatment options

Dr. Peter Rosenblatt tackled the issue of “Innovation or experimentation: Where do we draw the line?” in the TeLinde lecture. He started by describing a condition for which he feels we do not have an acceptable amount of treatment options for patients: fecal incontinence. He described how he observed that the puborectalis muscle, not the external anal sphincter, was critical for fecal continence. He then devised a surgery that created a sling that would act as a synthetic puborectalis muscle. He had amazing success until one patient had a serious complication. Should you abandon a successful, innovative surgery due to one very severe complication, was the question. Where do we draw the line? I don’t have an answer…but I do know that we all need to thank our puborectalis muscle for our daily fecal continence!

This is not a new issue in medicine, explained Dr. Rosenblatt. From the beginning of medicine, there has been a balance between innovation and experimentation. So, what is innovation? It is when someone improves upon a device or process. In medicine, is it innovation or just variation? We frequently use medications and devices “off label,” and these techniques often improve our surgeries and outcomes for our patients. Innovation comes about through careful planning, a necessity created by an emergency, advances in technology, and through evolution of a procedure. Who are the innovators? YOU are! We are the ones who understand the unmet needs and the potential opportunities for improving medicine. Let’s all work together to innovate NOT experiment and make medicine better so our patients have the best care possible!

“New Frontiers in Gynecologic Surgery: Transgender Surgery and Functional Clitoroplasty after Female Genital Mutilation”

The final talk for the day was by the groundbreaking Dr. Marci Bowers, whose lecture started by reminding everyone that there is a difference between gender identity and gender expression. Once a person knows his or her gender identity they use gender expression to express this to the world, she pointed out. Dr. Bowers is a true innovator and is performing gender reassignment surgeries as well as female genital mutilation corrective surgeries. She has perfected a one-stage vaginoplasty, and she showed a video of the procedure, which results in a 90% chance of orgasm. She also noted that she is able to restore clitoral function in 100% of the cases of genital mutilation, and she performs these procedures free of charge.

She reminded us that all ObGyns need to be trained in treating transgender patients, and given the high rate of suicide among adolescent transgender individuals, we all need to work together to provide a supportive medical environment to help these patients. What a fascinating end to the day!

Some relaxation, and entertainment, amid the sun and outdoors

We then had the afternoon to compete in a golf tournament, explore the area on mountain bikes, or lounge by the pool. Regardless of the daytime activities, we all came back together for the great lip-synch competition! All 4 teams gave an impressive performance, but the team from Brown University went home with the win! Such an entertaining event! (Thanks to incoming SGS President Vivian Sung @wih_sung for the pic!)

4/11/16. DAY 2 AT SGS

Experts talk surgical innovations, complementary therapies, value-based payment, and much more at SGS day 2

Wake up and learn! The second day of the 42nd Annual Scientific Meeting of the Society of Gynecologic Surgeons began with a review of research posters at the Poster Session as the sun rose over the Palm Springs mountains. We then moved indoors for the scientific sessions.

In the first lecture, "Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease," Dr. Courtney Penn and colleagues reiterated that the postsurgical readmission rate is higher for patients undergoing abdominal hysterectomy compared with those who have a laparoscopic or vaginal hysterectomy. Similarly, Dr. Jennifer Schmitt and colleagues suggested that in a patient with a relative contraindication for vaginal hysterectomy, when this procedure is performed by an experienced surgeon there may not be increased complications. However, keep in mind that the study described—"A Comparison of Vaginal and Robotic Hysterectomy for Commonly Cited Relative Contraindications to Vaginal Hysterectomy"—was performed at the Mayo Clinic by expert, highly trained surgeons, and this fact may limit the generalizability of the study. As one audience member eloquently stated, it is important to remember that: "Just because it is feasible does not mean it is the correct procedure."

That yoga or barre class may be doing more good than you think! Lunge, bridge, and cat-into-cow movements may provide a greater degree of pelvic floor muscle unit recruitment than traditional Kegel exercises, according to a presentation by Dr. Bruce Crawford on Kegels versus specialized movement.

Perhaps those exercises should be recommended for surgeons as well. As Dr. Ruchira Singh pointed out, surgeons experience a high amount of musculoskeletal strain when performing vaginal procedures while sitting, regardless of the type of chair used during surgery. Dr. Singh and colleagues’ study, "Effect of Different Chairs on Work-Related Musculoskeletal Discomfort During Vaginal Surgery," found that while the round stool with a backrest and the Capisco chair were more comfortable, they did not eliminate the high risk for musculoskeletal strain, particularly in the head and neck.

Dr. Ann Peters and colleagues, from Magee-Womens Hospital of the University of Pittsburgh Medical Center, gave a fabulous video presentation on "Anatomic and Vascular Considerations in Laparoscopic Uterine Artery Ligation During Hysterectomy."

Need a novel treatment for interstitial cystitis/bladder pain syndrome? Consider mindfulness-based stress reduction. A randomized controlled study performed by Dr. Gregg Kanter and colleagues describes how this technique may help patients and could be considered a first-line therapy.

What is value-based payment and this new trend in reimbursement? And how does it apply to vaginal hysterectomy? Dr. Tina Groat addressed these issues in her keynote lecture. According to the American Congress of Obstetricians and Gynecologists, “Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy.” This is in opposition to what is actually being performed clinically. Dr. Groat explained that United Healthcare decided to incentivize physicians by requiring a prior authorization for all hysterectomies for benign disease. There is both a quality and cost benefit to performing a vaginal hysterectomy. Most insurance companies are moving away from a “fee for service” structure to performance-based payment. Change is always scary and, while I think the overall goal of moving toward the best care for our patients is a positive, this approach may create new challenges for the medical field. What do you think? Is performance-based payment beneficial? Or does it limit physicians and potentially force them to perform a procedure they do not feel as comfortable performing? Will this result in physicians rejecting certain patient populations? [Note from OBG MANAGEMENT: Let Dr. Collins know your thoughts through social media, or email OBG MANAGEMENT with a Letter to the Editor (rbarbieri@frontlinemedcom.com).]

The debate on the best route for hysterectomy continues: According to Dr. Carolyn Swenson and colleagues in their presentation, "Comparison of Robotic and Other Minimally Invasive Routes of Hysterectomy for Benign Indications," while there may be lower complications associated with robotic hysterectomy, the cost of performing a robotic hysterectomy is significantly higher than the cost of laparoscopic or vaginal hysterectomy, thus limiting its utility.

How can we teach a rare surgical procedure to learners? We channel our inner Martha Stewart and make a model out of a beef tongue and chicken. For about $8 a challenging and rare surgery can be taught to residents and medical students, according to the video presentation by Dr. Jana Illston and colleagues, titled "Modified Beef Tongue Model for Fourth-Degree Laceration Repair Simulation."

After the Day 2 lunch break, there was a rousing debate surrounding "Surgeons as Innovators—What Is the Patient Expecting?" Where do we draw the line between using an older more proven therapy as opposed to trying an innovative technology that may actually offer a potential benefit? Dr. Dennis Miller made a good point regarding innovation and pharmaceutical and device companies: If we ignore industry, we lose the ability to help with innovation and shape the future of medical treatments. Perhaps we should use the golden rule: If we would perform the surgery or use the device on ourselves, then we should perform it on our patient. Patients have a greater burden now, because there are more treatment options that they must choose among. Our job as physicians is to educate our patients and to guide them to innovative and evidence-based treatments.

Highlights from the afternoon oral poster session included a presentation by Dr. Caryn Russman that noted the high risk for recurrent urinary tract infection (UTI) after a mid-urethral sling procedure, which seems to be related to specific preoperative risk factors (such as a history of recurrent UTI). Dr. Tanya Hoke suggested that residents and attending physicians have inaccurate estimates of uterine weight, and an educational program may be necessary to improve these estimates. Finally, a study from Massachusetts General Hospital showed that a shorter stay in the hospital, ideally same-day surgery, resulted in a lower complication risk, lower number of emergency department visits, and a decreased readmission rate for patients undergoing urogynecology procedures.

The following recommendations were then suggested regarding vaginal hysterectomy:

• Preoperative prep with 4% chlorhexidine or povidine iodine
• Intracervical vasopressin injection to decrease blood loss
• Use of a pedicle-sealing device for pedicle ligation
• Vertical cuff closure is preferred to maximize vaginal length

Another important point made was that a prior cesarean delivery is not a contraindication to performing a vaginal hysterectomy.

Recommendations regarding recurrent UTI were also made, which include the recommendation for preoperative use of antibiotics to decrease the rate of UTI, with no benefit for a longer course of antibiotics.

News from the Fellows’ Pelvic Research Network

So much exciting research currently is ongoing with the FPRN! New project ideas include comparison of trimethoprim with methenamie for treatment of recurrent UTI; comparison of laparoscopic/robotic sacrocolpopexy with vaginal USLS for management of apical prolapse; a survey study examining surgeon preferences for timing of midurethral sling placement when performed at the time of pelvic organ prolapse (POP) repair; an assessment of the effect of a midurethal sling on overactive bladder in surgical repair in POP; and a study evaluating female pelvic reconstructive surgery in the setting of human immunodeficiency virus infection. It is so great to see the fellows working together to provide groundbreaking research!

Fun with stats

Learning statistics at the end of the day is never easy, but Dr. Matthew Barber did a fabulous job explaining this often-confusing topic. He reminded attendees that the key to learning statistics is repetition. One new recommendation he offered to enhance understanding is to use common language instead of numbers for P values. For example, instead of saying P <.001, use “is superior,” and instead of saying P = .3, use “seems not superior” or “inconclusive.”

A night to remember

The night ended with a wonderful awards ceremony and the president’s reception. Overall, day 2 was a very educational—and fun—day!

4/10/16. DAY 1 AT SGS

Postgrad courses address pain management and social media education

Mastering pelvic pain

With the beautiful Palm Springs, California, backdrop of mountains and palm trees, the 2016 meeting of the Society of Gynecologic Surgeons kicked off with 4 postgraduate courses. At the “Mastering Pelvic Pain: Strategies and Techniques for a Multimodal Approach” course, directed by Dr. Cara King, Dr. Matt Siedhoff explained the key components of the history and physical examination: Keep in mind that this generally is a multifactorial issue and may require a multidisciplinary approach, he told attendees. It is also important to make sure that the patient is fully prepared to combat the chronic pelvic pain (CPP) symptoms by focusing on the fundamentals, he said, including smoking, diet, exercise, weight loss, sleep, and relationship stress.

How is your posture? It turns out that something as simple as altering your posture can significantly affect pelvic floor control. Carol Sobeck, PT, demonstrated this importance with a simple group exercise that proved how the ability to contract the pelvic floor changes significantly with posture. Get to know your pelvic floor physical therapist—they are critical in helping with the treatment of CPP.

But what to do when physical therapy fails? Dr. Jennifer Gunter shed some light on this very difficult medical situation. One suggestion, she said, is to consider the possibility of a local presentation of a systemic issue and screen for the following: fibromyalgia, Ehlers-Danlos syndrome, statin use, and diabetes mellitus. Other treatment ideas include trigger point injections and onabotulinumtoxin A (Botox) therapy. A trigger point is a hypercontracted focus of muscle. To treat a trigger point, a needle must mechanically disrupt the trigger point to reduce the pelvic pain, and injection of local anesthetic is only used to help with postprocedure discomfort. Botox in my pelvis, you ask? Yes! The goal is to block presynaptic release of acetylcholine, which is very effective at reducing muscle spasm. 

Tackling endometriosis. Dr. King then described surgical techniques for endometriosis. She recommended that, for mild disease not in close proximity to vital structures, ablation is likely equivalent to excision. For deeply infiltrating endometriosis, or lesions in close proximity to vital structures, excision is more beneficial. Excision is always beneficial for pathologic diagnosis, she said. And she offered this tip for bladder endometriosis: place a stitch in the nodule to allow for counter traction. Here is another tip, for ovarian cystectomy: inject vasopressin (20 U in 60 mL) to help dissect the plane between the ovary and cyst wall, and consider presacral neurectomy for midline pain.

Dr. Frank Tu then explained that we should not think of it as the “terrible triad: endometriosis, irritable bowel syndrome, and interstitial cystsis,” but rather as a system out of balance. Both peripheral and central mechanisms are involved in the generation and maintenance of cross-organ sensitization, he pointed out, which may explain why patients receive multiple diagnoses that describe a myriad of complaints due to a lack of overall homeostasis.

While Dr. Alaa Abd-Elsayed described innovative nerve blocks for CPP, he emphasized that no one specific treatment will result in a complete resolution of symptoms.

Vaginal mesh placement and pain. Dr. Mario Castellanos gave a fabulous lecture describing the pain issues that surround vaginal mesh placement. Interestingly, he noted that many patients had pelvic pain prior to placement of vaginal mesh, and that pain likely only will worsen with mesh placement. Mesh may cause pain by causing inflammation, visceral injury, muscle injury, and nerve injury. While there are guidelines for where mesh should be placed for bladder slings (TVT and TOT) and for prolapse repair, studies show, he pointed out, that the mesh placement often disrupts several muscle groups and may directly injure a nerve.

Alternatives to the typical diagnoses for CPP. The morning ended with a lecture by Dr. Suzie As-Sanie, in which she reminded everyone to start with “gold standard” therapy but, if those fail, consider alternative diagnoses or a central pain disorder. She also suggested cognitive behavioral therapy for treatment of CPP. For patients who cannot afford cognitive behavioral therapy, there is a free online source at fibroguide.med.umich.edu. Other alternative treatment options include exercise, patient education, instruction on sleep hygiene, and neurostimulatory therapies.

Overall, all the speakers this morning agreed that CPP is rarely treated with one modality, and it is best treated with a multidisciplinary approach.

Let’s get social!

The afternoon was spent learning about ways to use social networking sites to educate our patients, in another postgraduate course on “Making Media Social,” presented by the SGS Social Media Committee. Given that a recent survey demonstrated that 74.1% of women have some type of social networking account, it can be a very useful source for medical information for patients. If you have any questions about what is appropriate on social media, check out ACOG committee opinion 622.

Here are some tips that I learned:

Facebook:

• Keep your private Facebook page private and create a separate professional Facebook page
• Adjust your login setting so only administrators can post on your professional page
• Adjust settings so your professional profile cannot be “tagged”
• If a patient contacts your personal page, direct them to your professional page
• Do not give medical advice since Facebook is not digitally encrypted

Twitter:

• “Short bursts of inconsequential information”
• Follow societies, medical centers, and medical journals

LinkedIn:

• It provides a great way to find jobs, people, and business opportunities that are recommended by someone in your contact group
• It is specifically there to help you grow your business and show people who you are and where you have come from

Doximity:
Before we get to tips, first, what is it? Well, Doximity is basically a “LinkedIn” for physicians. It is “a way to find relevant specialists for patients; a rolodex; an email and text service; and a virtual lounge.” It is currently transforming from social network into a ‘platform.’ Now more than 1,000 hospitals and health systems are part of Doximity. Tips:

• There is a secure message option, which is HIPAA compliant
• Provides a way for residents and fellows to understand possible future places of employment
• It is a great way to find someone to refer patients to in an unfamiliar location

Vimeo:

• A benefit over YouTube is the lack of advertisements
• Check out the SGS video archives!
• You also can set privacy settings and embedding stats

Fifty-nine percent of US adults have looked online for health information in the past year. Therefore, it is important for physicians to get good information out for people to see!

A relaxing day’s end

The night ended with a beautiful poolside reception! I can’t wait to see what day 2 will bring!