Urogynecology Fellowship

Organization of Inpatient and Outpatient Teaching:

Inpatient teaching in the Department of Obstetrics and Gynecology is organized on four basic rotations:

1. Main Campus Urogynecology/Pelvic Reconstructive Surgery (80% clinical/20%research)
2. East-side Urogynecology/Pelvic Reconstructive Surgery – Hillcrest Hospital and Main Campus (80% clinical/20% research),
3. West-side Urogynecology/Pelvic Reconstructive Surgery – Fairview Hospital and Main Campus (60% clinical, 40% research)
4. Research rotation (100% protected research).

The large clinical volume provides a broad-based exposure to clinical Urogynecology/Reconstructive Pelvic Surgery marked by progressive responsibility both in the clinic and hospital. The fellows work with five gynecologists with different areas of expertise (Urogynecology, urodynamic testing, vaginal reconstructive surgery, operative endoscopy, robotics, etc.) who have a total of over 80 years of clinical experience. Additionally, fellows work with Drs. Brooke Gurland , Tracy Hull, and Massarat Zutshi, colorectal surgeons recognized for their work in anal incontinence and defecatory dysfunction, and with Drs. Sandip Vasavada, Raymond Rackley, Howard Goldman and Courtenay Moore, nationally recognized urologists who specialize in female urology and voiding disorders.

All gynecology patients are admitted to the Cleveland Clinic Main Campus, Hillcrest Hospital, or Fairview Hospital. At Main Campus, the Urogynecology Service consists of an Urogynecology/Reconstructive Pelvic Surgery (FPMRS) fellow; fourth-year, third-year, and first-year Cleveland Clinic/MetroHealth Medical Center residents and a third-year Cleveland Clinic Lerner College of Medicine or Case Western Reserve University Medical Student. At times there will be a fourth-year medical student or third-year visiting resident doing an elective in Gynecologic Surgery. The primary responsibility of this team, under the direction of the FPMRS fellow and appropriate staff members, is the direct care of all hospitalized urogynecology patients. Morning work-rounds and surgery assignments are supervised and organized by the fellow. Afternoon/postoperative rounds and hospital GYN consults are likewise organized by the fellow and directly supervised by the gynecology faculty, if needed. On this rotation the resident and fellow generally operate four weekdays on a busy surgical schedule. Combined cases with General Surgery, Colorectal Surgery and Urology are common. To assist the FPMRS team in their hospital duties, a gynecology case floor manager, home care coordinator, and social worker are available as needed. Outpatient gynecology nurses assist in the follow-up of surgical patients with bladder catheters.

For the East Side and West Side Urogynecology/Pelvic Reconstructive Surgery rotations, fellows will operate at Hillcrest and Fairview hospitals once per week and Main Campus 1-2 days per week. During these rotations, fellows will also have 2-3 days per week of non-surgical time allocated to surgical simulation, research and outpatient experiences in urodynamics, pelvic floor physical therapy, and Colorectal Surgery clinic. A dry lab and computer simulator are available to teach and practice laparoscopic suturing techniques. An anatomy laboratory is available and research and educational opportunities that include cadaver dissection are are available.

The research rotation consists of 100% protected research time with the exception of a weekly continuity clinic. Research activities in surgical teaching and simulation, urodynamic testing, surgical techniques, other basic science and anatomy topics, and surgical videos are available.

All outpatients are seen in the outpatient clinic located on the same campus as the Main hospital, Hillcrest Hospital, or Fairview Hospital. It is during these times that initial examinations and urodynamic assessments, including management decisions and plans for surgery, are reviewed and implemented.

The primary night-call responsibility is rotated among the residents assigned to the Gynecology Service. The fellows are available out of hospital for back-up call for all Urogynecology and Pelvic Reconstructive Surgery calls and consults. One of the benign gynecology faculty is on-call in house and one Urogynecology faculty is also on-call from home at all times for resident or fellow consultation and problem management. The fellow, residents, and urogynecology faculty on-call conduct weekend rounds. Fellows are also required to take in-house call approximately once monthly serving as the in-house gynecology attending physician. Fortunately, the fellow is compensated for this additional work.

The fellow in surgery is directly supervised and advised by the faculty at all times. The goal of the fellowship is to provide a large volume, extensive surgical experience with approximately eight months of surgical rotations each year. This will provide the fellow with an extensive range of procedures, even for very rare and difficult conditions. The gynecology faculty is in attendance in the operating room during the critical portions of all procedures. Fellows are accorded progressive surgical responsibility based on individual assessment of expertise. When other consultants are required to assure optimal patient care or when combined specialty cases are being performed, the fellow continues their surgical participation at the direction of either the Colorectal or Urologic consultant.

The FPMRS fellows participate in various regular educational conferences and seminars including three mandatory weekly conferences:

Pelvic Floor Center Conference (Tuesdays, 5pm) - The Pelvic Floor Center Conferences are attended by Urogynecology, Female Urology, Colo-rectal Surgery faculty and fellows along with interested members of the Departments of Biomedical Engineering, Quantitative Health Sciences and Physical Therapy. These conferences include monthly lectures, journal club, case conferences, and research meetings. Fellows are asked to perform lectures or moderate journal clubs several times each year. Topics includes anatomy; basic and advanced urodynamic testing; pathophysiology and surgical management of stress urinary incontinence; pathophysiology, physical assessment and surgical management of pelvic organ prolapse; detrusor overactivity; repair of surgical injuries to the lower urinary tract; voiding disorders; suburethral diverticula/fistula; and other topics.

Fellow Seminar (Tuesdays, 4pm) - the fellows participate in a weekly fellow seminar dedicated to urogynecology topic reviews, case conferences, and monthly research seminars, which include discussion of research design, statistics, grantsmanship, and research management. A 6-topic seminar on surgical education is also incorporated into this weekly conference.

Ob/Gyn Grand Rounds (Wednesdays, 7am) - The FPMRS fellows participate in weekly departmental Grand Rounds. Included in these conferences are monthly GYN Quality Assurance and Improvement meetings. The fellows actively participate in these conferences and present all pertinent patient materials. The fellows serve as the Grand Rounds Presenter at least twice during their three years (2^nd and 3^rd year).

The fellows may participate in and share teaching responsibilities in the medical student core lecture program and the weekly Resident Education Conferences during which a core-curriculum of material is presented on an annual basis. Additional conferences include those in the Minimally-Invasive Surgery Center and selected conferences in the Departments of Urology and Colorectal Surgery, as time permits. These programs are offered throughout the academic year.

The fellows actively participate in the Annual Cleveland Society of Obstetricians and Gynecologists Research Day and in appropriate departmental postgraduate courses. The fellows submit their current research for presentation in the form of poster presentations or oral presentations at these meetings.

Fellows attend a minimum of one meeting per year (more for research presentations) and have the opportunity to attend the Annual Meetings of the Society of Gynecologic Surgeons, the American Urogynecology Society, ACOG, AAGL, or other national or international meetings, as appropriate. Active participation, including presentation, is encouraged at all meetings to promote the fellow’s experience and expertise in scientific meeting participation.

Fellows are to take two graduate level courses as part of the fellowship. These courses, including Biostatistics and Epidemiology, are taught by faculty of the Cleveland Clinic Lerner College of Medicine or at CWRU and are typically taken in the first and second year of fellowship.

The research activities of the fellows are an integral part of their educational experience. It is expected that fellows will enter the program with an interest in research, with varying backgrounds and levels of previous experience with research. In the first year of the fellowship, didactic conferences provide the framework necessary for the fellows to develop into independent researchers. Dr. Barber organizes the conferences, with invited lectures from staff in the Department of Quantitative Health Sciences and Bioethics. The lectures cover the basic elements of epidemiology, clinical research design, data analysis and interpretation. Additionally, Center for Female Pelvic Medicine and Reconstructive Surgery holds monthly research meetings that include faculty from the Departments of Ob/GYN, Urology, Colorectal Surgery, and Quantitative Health Sciences where potential collaborative research projects are developed and on-going research projects are discussed. Within this structure, fellows learn how to proceed from identifying a research question to developing a research protocol.

Fellows are expected to initiate and complete their own independent research. At the beginning of the fellowship, each fellow meets with the Program Director to explore areas of interest. Once specific topics are chosen, with guidance from a designated faculty member and using resources both within and outside the department, the fellow works through the steps of formulating a specific research question, determining the most appropriate study design, and developing the research protocol including plans for data collection and analysis. The proposed project is presented for critical review to a committee composed the Program Director, the fellow’s Faculty research mentor and other interested faculty. As appropriate, the protocol is reviewed and approved by the Institutional Review Board at the Cleveland Clinic. Personnel support such as research nurses are provided; additional funding, if necessary, is available by application to the institution’s Research Programs Committee or through outside funding sources. It is anticipated that the fellows will gain experience in writing grant proposals for Federal and non-Federal research funding.

Obviously, the choice of study design varies by the nature of the research question. Clinical research projects can be performed either retrospectively or prospectively. There is a wealth of clinical material available for retrospective study at our institution. Senior members of the Department of Obstetrics and Gynecology have been performing between 500 and 600 surgical cases per year related to prolapse and incontinence for approximately the past 20 years. Inpatient and outpatient Cleveland Clinic records are maintained in EPIC (Electronic Patient Information Chart). Records are computerized by diagnosis and surgical procedure, which allows for easy identification of study groups.

The fellows are strongly encouraged to develop prospective trials in gynecologic surgery, especially related to urinary and fecal incontinence, pelvic organ prolapse, and other pelvic floor diseases. Potential subjects for prospective studies are available through the practice of all faculty members in the Department of Obstetrics and Gynecology, and other departments, as appropriate. Funding for projects may be available through the CCF Research Program Council, as well as through the Minimally Invasive Surgery Center. Research nursing support is available for the identification,

recruitment, enrollment and tracking of subjects in prospective studies. Data management is facilitated with the use of computerized databases.

The fellows also have an opportunity to perform basic science research in several laboratories within the Pelvic Floor Center. Dr. Margot Damaser in the Department of Biomedical Engineering has an active laboratory focusing on the biomechanics and neuromuscular control of the lower urinary tract and female pelvic floor, particularly with regard to injuries incurred during childbirth. Over fifteen investigators including post-doctoral fellows, graduate students in biomechanical engineering, FPMRS fellows and urology residents perform research in one of the three laboratory facilities supervised by Dr. Damaser. Ongoing research include developing and using animal models of stress urinary incontinence and fecal incontinence to determine the mechanisms of injury that occur in vaginal delivery and devise methods of treating and/or preventing development of SUI and FI. Methods under investigation include facilitation of innate stem cell homing to the pelvic floor organs and tissues; hormonal supplementation; or use of neuroregenerative agents. A second major focus of study for this lab is the characterization of genetic mouse model of pelvic organ prolapse (Loxl 1 knock-out mice) and investigating its potential for use in identifying those patients most at risk for pelvic floor disorders as well as in development of new treatments for female pelvic floor disorders. Additional research being performed in Dr. Damaser’s lab in which FPMRS fellows are or have been involved include the development of a functional virtual reality model of the female pelvic floor and investigations using animal models of fecal incontinence. Additionally, basic science laboratories in the Glickman Urological Institute are available to the fellows.

The Cleveland Clinic Center for Surgical Innovation Technology and Education (cSITE), formerly the Minimally Invasive Surgery Center, supports both basic science and clinical research of new surgical innovations through research funding and houses an advanced basic science and clinical research facility available to fellows. Ongoing FPMRS fellow-initiated clinical projects funded by cSITE include a prospective randomized trial comparing conventional laparoscopic versus robotically-assisted sacral colpopexy for treatment of advanced pelvic organ prolapse and a prospective randomized trial of conventional laparoscopic versus robotically assisted laparoscopic hysterectomy for benign gynecologic disease. Both of these projects were designed by former FPMRS fellows and the fellows served as principal investigators of the project. The laboratory components of the cSITE research facilities include a state-of-the-art animal lab for survival studies and anatomic teaching/research lab. The vivarium is set up for large and small animal surgical studies. There is a support area for animal preparation and care from veterinary services. Two operating rooms are available for experimental studies, which range from new abdominal procedures to minimally invasive cardiac procedures. One operating room is set up with state-of-the-art endoscopic and telecommunication equipment. This experimental area is shared by Colorectal Surgery, Urology, and other specialties so that collaboration is facilitated. The anatomic teaching/research laboratory has two components: first, a lab for cadaver and animal work (wet lab) and second, a lab for simulation model training (dry lab). The wet lab facility is equipped with eight stations, full function OR tables, full anesthetic equipment and operating instruments to simulate a real operating room experience as well as fresh frozen cadaver storage facilities and a full-time dedicated support staff.

It is important that the fellows be totally exposed to the process and proceedings of large collaborative multicenter research trials and the process of NIH grants. In addition to initiating and completing their own independent research projects, fellows may also participate in multicenter research projects, research projects funded in other departments such as Urology, and through corporate grants. The Cleveland Clinic is a member of the NIH Pelvic Floor Disorders Network (PFDN) and fellows are encouraged to participate in PFDN protocols. This includes recruiting patients, administering treatments, and performing follow-up examinations. Additionally, data from the pelvic floor disorders network studies are available for secondary or ancillary analyses to all members of the PFDN clinical site. Through this organization, fellows may have the opportunity to work on multicenter trials and to gain exposure to national leaders in gynecologic surgery. It is also anticipated that the fellows will gain experience in writing grant proposals for Federal and non-Federal research funding.

We recognize that current and future care of patients with pelvic floor disorders will involve cooperation among specialties and sometimes requiring multidisciplinary collaborative care. The intent of all off-service rotations during the fellowship is to supplement the fellow’s experience in U/RPS by exposing them to fields that are important to their future care of patients. The Cleveland Clinic is fortunate to have multiple centers of excellence and these will be used to improve our fellows’ education. We currently have two months/year of formal surgical rotation on the Urology Service by the 3rd year fellow. Here they learn an expanded repertoire of surgical techniques, especially sacral neuromodulation. The multidisciplinary collaborations are further enhanced by the CCF Center for Female Pelvic Medicine and Reconstructive Surgery. This provides not only off-service rotations but also ongoing cross-service educational programs and access to subspecialists in Urology, Colorectal Surgery, and Physical Therapy.

The fellows are expected to assume progressive responsibility and independence during the fellowship with the eventual goal of independent practice in General Gynecology, Operative Laparoscopy, and Urogynecology/Reconstructive Pelvic Surgery. The initial experiences in the outpatient clinics and in surgery are closely monitored and supervised until clinical expertise has been demonstrated. At this point, progressive responsibility, both in the ambulatory as well as operative care of patients, is given to the fellow. This includes more independent functioning within surgery; however, gynecology faculty continues to be present within the operating room and is scrubbed during the critical portions of all procedures. As noted previously in regard to surgical responsibility, the fellow progressively assumes the responsibilities of primary surgeon or, in the case of less extensive cases, is the first assistant to instruct the junior fellow or resident. This progression occurs over a three-year period of time and will be paced to meet the abilities and experience of each individual fellow. In addition to clinical responsibility, it is expected that fellows will also progress in their abilities to conduct independent research, teaching of residents and medical students, and administrative duties. The program director and other faculty regularly meet with the fellows to assess their progress so that individual weaknesses can be identified and remedied and increased responsibility assumed.