Preoperative Simulation of Retropubic Midurethral Sling to Decrease Bladder Perforation Rate Among Obstetrics and Gynecology Residents

Importance Bladder perforation is an often avoidable complication of retropubic midurethral sling procedures. Bladder injury rates decrease with surgeon experience, but literature on techniques to train novice surgeons is limited. Objective Our objective was to decrease the bladder perforation rate among obstetrics and gynecology residents during retropubic midurethral sling procedures through implementation of an instructional video and low-fidelity simulation. Study Design A baseline bladder perforation rate was determined by retrospective chart review. A prospective educational intervention, consisting of a 10-minute instructional video with preoperative simulation using a simple bony pelvis model, was then implemented among residents on the urogynecology service from December 2017 through March 2020. The primary outcome was the change in the bladder perforation rate. Compliance with the intervention protocol was a secondary outcome. Categorical data were evaluated using the χ² or Fisher exact test. Continuous variables were assessed using the Student t test or Mann-Whitney U test as appropriate. Results Two hundred fifteen retropubic midurethral sling cases were included in analysis. There were no significant demographic differences between the patients undergoing surgery preintervention and postintervention. Resident surgeons were in their second (47.4%) and third (52.6%) years of training. The postintervention bladder perforation rate was 6.5%, which is a 35% reduction from the preintervention perforation rate of 10% (P = 0.19). The instructional video and preoperative simulation were successfully implemented in 193 of 215 (89.8%) eligible cases. Conclusion Despite high compliance, the combination of the instructional video and preoperative low-fidelity bony pelvis simulation was not effective in reducing tension-free vaginal tape-associated bladder perforations among residents.