Development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and a Clinical Teaching

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Video Description

OBJECTIVE: To create an inexpensive and useful simulation training model for surgical skill training of the retropubic TVT procedure for OB/GYN residents

DESIGN: Prospective Cohort Study INTERVENTIONS This video includes the clinical context of R-TVT use for residents learning this surgery. The video also demonstrates the model’s creation and its use in resident simulation training of the R-TVT procedure. The R-TVT simulation model was fabricated for a total cost under $100 with the use of a pelvic model and modelling clay that can be re-used.

Training with the model includes a teaching video outlining the surgical steps of the procedure from an expert surgeon. It is meant to be used for further research to examine its effectiveness in teaching residents using objective measures and resident self-assessment.

CONCLUSION: An inexpensive and practical R-TVT simulation model can be created that has the potential to aid residents in learning this skill.

Presented By

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Dr. Naomi Reaka
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Dr. Carolyn Best
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Dr. Ola Malabarey


McMaster University

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What is Development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and a Clinical Teaching?

The development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and its integration into clinical teaching is an educational strategy designed to improve surgical skills specifically related to the TVT procedure, which is commonly used to treat stress urinary incontinence (SUI).

  • A minimally invasive surgical procedure to help support the urethra, used in cases of SUI, which is involuntary urine leakage prompted by physical activity or exertion.
  • Involves the placement of a mesh tape under the urethra through a small vaginal incision, providing the necessary support to prevent unintentional urine leakage.
  • Incorporation of the TVT simulation model into surgical education programs or courses.
  • Provides hands-on experience and augments traditional learning methods, such as lectures or shadowing.
  • Enables trainees to make mistakes and learn from them without any risk to actual patients.

Benefits may include:

  • Improved surgical competence and confidence among trainees.
  • Reduced learning curve associated with complex surgical procedures.
  • Potentially decrease the rate of complications when trainees proceed to real-life surgeries.
  • Facilitates the assessment of a surgeon’s readiness to perform the procedure independently.

What are the Risks of Development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and a Clinical Teaching?

While the development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and its use in clinical teaching are largely beneficial, there are potential risks and challenges associated with this educational approach:

  • Resource Intensive:

    • Development and maintenance of high-fidelity simulation models can be costly.
    • Requires ongoing funding for up-to-date equipment, space, and trained personnel to facilitate the simulations.
  • Simulation Limitations:

    • Simulations may not be able to fully replicate the variability and complexities of human anatomy and patient responses.
    • There’s a risk that trainees may develop overconfidence if the simulation does not accurately reflect the challenges of real-life surgeries.
  • Learning Curve:

    • Instructors must be adequately trained to teach using the models, which may require additional time and resources.
    • Trainees may have varying learning curves, and the simulation may not be equally effective for everyone.
  • Equipment Shortcomings:

    • If the model does not accurately represent human tissue or does not replicate the surgical environment closely, it may fail to prepare surgeons for the tactile and visual differences they’ll encounter during actual surgeries.
  • Standardization and Assessment Challenges:

    • Difficulty in standardizing assessment criteria for performance during simulations.
    • Evaluating competency based on simulation performance can be subjective, depending on the evaluator’s judgment.
  • Complacency Risk:

    • Repeated practice on a known model might lead to complacency among trainees, reducing their preparedness for unexpected challenges in real procedures.
  • Ethical and Legal Considerations:

    • Ensuring the simulation practices are ethically sound, especially when using animal or human tissues.
    • Potential legal considerations regarding the consent of using patient data or images to create models.
  • Technology Dependence:

    • Over-reliance on technology might overshadow the importance of theoretical knowledge and traditional learning methods.

Despite these challenges, the integration of simulation models like the TVT into clinical teaching is considered a significant advancement in medical education, helping to bridge the gap between theory and practice while enhancing patient safety and surgical outcomes.

Video Transcript: Development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and a Clinical Teaching

In this video from myself and colleagues at McMaster University we describe the development of a retropubic TVT simulation model and its use via a clinical teaching video for OBGYN residents.

The objectives of this video are to provide background clinical information on the relevance of TVT insertion skill learning and the benefits of simulation for this surgery. We will demonstrate the use of the TVT simulation model in a teaching video directed for OBGYN residents as a part of our future research study.

Stress urinary incontinence is the involuntary leak of urine with increased intraabdominal pressures such as when coughing, laughing, or sneezing. Prevalence estimates range between 10 to 55% among females aged 15 to 64 years old. Risk factors include those that weaken the pelvic floor.

Evaluation for SUI includes a focused history, physical examination, and ruling out voiding dysfunction with a post-void residual. As this is a quality-of-life issue, acceptability of various treatment options depend on the risk, benefit profile for the patient.

Expectant management, pelvic floor physiotherapy, pessaries, and various surgical managements are available. The number one surgical standard of treatment of SUI, given in large part due to its high success rate and shortened OR time requirements, is the TVT.

As the TVT insertion process relies on passage through pelvic spaces where there is an intricate condensed network of blood vessels and organs, there is a risk of haemorrhage and a 0.5% risk of iliac artery injury. Bladder and urethral injury are also possible risks. Listed here are possible postop complications.

The importance of proper movement of the TVT insertion trochar is essential as this is a blind skill. Preceptors watching cannot see the path of the trochar and learners may not be familiar with the path the trochar is supposed to take. This can create heightened anxiety and discomfort for both the preceptor and learner.

We know from an abundance of literature that simulation can help with surgical skills. Also, discomfort with surgical skills has been shown to be associated with perceived inferiority and performance, resulting in less confidence in the skill.

Practitioners therefore may not offer this skill to patients placing the burden on those patients waiting for this surgery for specifically trained surgeons.

We therefore sought to develop a TVT simulation model that was both affordable and easy to assemble. The total cost was under $100 with the majority arising from infrastructure materials such as the pelvic model. Expired TVT kits were donated to us, and the tissues were simulated with modelling clay that could be reformed and reused.

In this simulation we demonstrate the surgical steps to residents using the created model. We start by demonstrating how to handle the trochar and insert the sheath, followed by proper placement and motions for placement of the sheaths. Confirmation of appropriate placement and tensioning will also be discussed. Tips will be given along the way from an expert surgeon.

So, this patient’s already had her counselling done. She’s in the operating room under an anaesthetic. She is in lithotomy position and her bladder is empty with a Foley catheter in place. You could use the catheter introducer to deviate the urethra and the bladder away from the site of insertion. So, we’re assuming that the tunnels are already created.

So, we will start on the right side of the patient with the urethra and the bladder deviated to the opposite side holding the TVT on top with a proper grip to avoid having the tissues try and push your hand sideways. So, you’re in full control.

So, we’ll start by going into the right tunnel of the bisection. Throughout the insertion your index of your nondominant hand is pinching the tip of the trochar between the patient and your finger. So, you’re holding it tight and guarding it, making sure you’re not perforating through the vaginal tissue.

As soon as the tip is right under the inferior pubic rami you keep your finger there pinching your trochar so it doesn’t go any further and you immediately drop your hand to change the angle.

The idea is hugging the bone with the TVT insertion. The closer you hug the bone, the less likely you are to perforate the bladder which is represented here with the Styrofoam.

 And you can see that the trochar is really hugging the bone. You’re not aiming lateral because then you can get blood vessels or nerves. And you’re basically aiming towards the patient’s ipsilateral shoulder.

 Again, dominant hand is holding the TVT trochar and your finger is guiding it. So, we are passing it through the bisection. My finger is pinching the trochar against the inferior pubic rami. As soon as the tip passes the inferior pubic rami and it’s going through the urogenital diaphragm, immediately you drop your hand.

Very important to make sure that the trochar is behind the bone before you drop your hand otherwise you’re going to place it in the labia. And it’s coming out hugging the bone.

And this is exactly where you want it to be. Around 1 to 2 cm off the midline, completely hugging the bone, away from the bladder, away from the urethra which is in the middle. Of course, at this point you take the catheter out and you do a cystoscopy as well as a urethroscopy to ensure that there’s no bladder or urethral perforation.

You will start by pulling both sides of the trochar out making sure that the mesh as it goes in, it doesn’t twist. You want it to sit nice and flat. And you will keep pulling until the plastic in the middle here separates.

I use a Metzenbaum scissor which would sit here as you tighten to make sure you’re not tensioning it. Because if you do that it will put the patient in urinary retention and that is not how it works. You’re basically just creating a platform to sit under the bladder neck. I’m pulling, and you can see how we leave a bit of space between the urethra and the TVT. Once that is done, you can cut the plastic off.

Strengths of the model include its low cost, reusability, and ability to simulate muscle movements for the insertion process. Though the model does not teach the suburethral dissection or tensioning steps, this can be taught in vivo.

 Finally, we will be conducting a research study to validate the model’s usefulness in helping resident performance and comfort with this surgical procedure.