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The Complexity of the Retropubic Midurethral Sling

A Cognitive Task Analysis

Ackenbom, Mary F. MD, MSc*†; Littleton, Eliza B. PhD; Mahmud, Fizza MS; Sutkin, Gary MD, MBA

Female Pelvic Medicine & Reconstructive Surgery: May 6, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/SPV.0000000000000736
Original Article: PDF Only

Objective The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon’s internal thought processes during the surgery.

Methods Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery.

Results Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps).

Conclusions The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.

From the *Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center;

University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and

Department of Obstetrics and Gynecology, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri.

Correspondence: Mary F. Ackenbom, MD, MSc, 300 Halket St, Pittsburgh, PA 15213. E-mail:

The authors have declared they have no conflicts of interest.

The authors received no financial support.

Oral Presentation at Pelvic Floor Disorders Week, American Urogynecologic Society 37th Annual Scientific Meeting; Denver, Colorado; September 27–October 1, 2016.

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