Bowel Obstruction After Sacrocolpopexy: A Case Series.

OBJECTIVES: Bowel obstruction after sacrocolpopexy (SC) can cause significant morbidity. The aim of this study was to delineate clinical and surgical factors associated with bowel obstruction after SC and to describe its presentation, management, and sequelae. METHODS: We performed a retrospective case series of patients who underwent open, laparoscopic, or robotic SC within a large health maintenance organization and a single academic medical center between January 1, 2009, and December 31, 2019. RESULTS: Of 3,231 patients who underwent SC, 32 (1.0%) experienced a bowel obstruction. Sacrocolpopexy was performed laparoscopically or robotically in 19 (59.4%) and abdominally in 13 (40.6%). The mean time to bowel obstruction was 1.9 years (SD, 2.5; range, 3 days to 8.8 years). In patients who experienced bowel obstruction, medical management was undertaken in 19 (61.3%) cases. Eight of the 13 (61.5%) surgically managed cases underwent bowel resection, and 3 cases (23.1%) reported partial mesh excision. Recurrent obstruction was seen in 2 (10.5%) of the medically managed and 2 (15.4%) of the surgically managed cases. CONCLUSIONS: Bowel obstruction is a rare complication of SC and our rate of at least 1.0% corroborates those in the literature. Obstruction occurs from days to years after SC. Nonsurgical management was effective in most cases, with low rates of recurrent obstruction. In surgically managed cases, the majority included bowel resection or mesh excision; however, mesh excision was not associated with a subsequent identifiable procedural intervention for recurrent prolapse. These data inform patient counseling and surgical planning before SC and aid in diagnosis and management of bowel obstruction after SC.

Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVE: This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. METHODS: A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. RESULTS: A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. CONCLUSIONS: For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

A Randomized Controlled Trial Assessing the Impact of Opioid-Specific Patient Counseling on Opioid Consumption and Disposal After Reconstructive Pelvic Surgery.

OBJECTIVES: This study aims to determine the effect of opioid-specific counseling on postdischarge opioid consumption and opioid storage/disposal patterns after reconstructive pelvic surgery. METHODS: In this multicenter randomized-controlled trial, participants were randomized to standard generalized counseling or opioid-specific perioperative counseling. Opioid-specific counseling was provided at the preoperative and 2-week postoperative visits with educational handouts about the risks of opioids and U.S. Food and Drug Administration recommendations for appropriate opioid storage and disposal. The primary outcome was morphine milligram equivalent (MME) consumption between hospital discharge and 2 weeks postoperatively. Secondary outcomes included opioid storage 2 weeks postoperatively, opioid disposal 6 weeks postoperatively, and rate of opioid refills. RESULTS: Among 70 opioid-specific and 65 standard counseling participants, there were no significant differences in demographic characteristics, type of surgery, concomitant hysterectomy, or perioperative complications. For the primary outcome, there was no significant difference in median opioid consumption between the 2 arms. Median (interquartile range) postdischarge MME consumption for all participants was 15 mg (0-75). Forty percent of participants denied postdischarge MME consumption. For secondary outcomes, there were no significant differences in appropriate opioid storage between groups. The appropriate disposal rate of unused opioid tablets 6 weeks after surgery was higher among participants who received opioid-specific counseling. The rate of opioid refill was 7.4%. CONCLUSIONS: Opioid-specific counseling did not affect postdischarge consumption but increased the disposal rate of unused opioid tablets 6 weeks postoperatively. Opioid-specific counseling could minimize the potential for opioid misuse by reducing the number of unused opioid tablets in patients' possession after surgery.

Is a Postvoid Residual Necessary? A Randomized Trial of Two Postoperative Voiding Protocols.

OBJECTIVES: This study aimed to compare a backfill-assisted voiding trial (VT) with and without a postvoid residual (PVR) after pelvic reconstructive surgery. METHODS: This was a nonblinded randomized controlled trial of women undergoing pelvic organ prolapse and/or stress incontinence surgery. Participants were randomized immediately after surgery to either a PVR VT or a PVR-free VT. Our primary outcome was the rate of VT failure at discharge. Secondary outcomes included days of catheterization, urinary tract infection (UTI), and prolonged voiding dysfunction. With a power of 80% and an α of 0.05, we needed 126 participants to detect a 25% difference in VT failure (60% in PVR VT vs 35% in PVR-free VT). RESULTS: Participants were enrolled from March 2017 to October 2017. Of the 150 participants, mean age was 59 years, and 33% underwent vaginal hysterectomy, 48% underwent anterior repair, and 75% underwent midurethral sling. Seventy-five (50%) were randomized to PVR VT and 75 (50%) to PVR-free VT, with no differences in baseline demographic or intraoperative characteristics between the 2 groups. Our primary outcome, VT failure, was not significantly different (53% PVR VT vs 53% PVR-free VT, P = 1.0). There were no significant differences in days of postoperative catheterization (1 [0, 4] in PVR VT vs 1 [0, 4] in PVR-free VT, P = 0.90), UTI (20% PVR VT vs 20% PVR-free VT, P = 1.0), or postoperative voiding dysfunction (4% PVR VT vs 5% PVR-free VT, P = 1.0). CONCLUSIONS: When performing a backfill-assisted VT, checking a PVR does not affect VT failure, postoperative duration of catheterization, UTI, or voiding dysfunction.

Extraction of a large vaginal calculus utilizing an ear, nose, throat mallet and osteotomes.

BACKGROUND: Previous case reports on vaginal calculi extraction have described the removal of small calculi facilitated via episiotomy or transabdominal incision. This surgical video demonstrates a novel technique of transvaginal extraction of a large calculus utilizing an ear, nose, and throat (ENT) mallet and osteotomes. CASE: An 86-year-old female with urgency incontinence and limited mobility presented with obstipation and was found to have an 8.8 cm vaginal calculus. She had a history of prior vaginal mesh exposure after a mid-urethral sling that was managed expectantly without surgical resection. Cystourethroscopy and anoscopy excluded fistula. The calculus was extracted utilizing an ENT mallet and osteotomes in < 90 min, and no recurrent vaginal mesh exposure was identified. CONCLUSION: An ENT mallet and osteotomes can be safely utilized to expedite extraction of a vaginal calculus.

Medical management of appendicitis in early-term pregnancy.

A 19-year-old G1 at 37 weeks presented with acute non-ruptured appendicitis. Her advanced gestational age and surgical anatomy presented a complex surgical scenario. She was treated with intravenous antibiotics and induction of labour, which resulted in resolution of the appendicitis and an uncomplicated vaginal delivery at early term. This case is an example that appendicitis occurring in early-term pregnancy can be successfully managed with intravenous antibiotics, but this is a complex clinical scenario with a limited evidence base to make management decisions. Future studies of medical management of appendicitis in pregnancy, specifically in later gestation, are needed to provide additional information to guide clinicians.

Transfusion Rates and the Utility of Type and Screen for Pelvic Organ Prolapse Surgery.

OBJECTIVES: Limited data exist directly comparing the likelihood of blood transfusion by route of apical pelvic organ prolapse (POP) surgery. In addition, limited evidence is available regarding the risk of not ordering preoperative type and screen (T&S) in apical POP surgery. The objectives of the study are to (1) provide baseline data regarding the current need for preoperative T&S by comparing perioperative blood transfusion rates between 3 routes of apical POP surgery and (2) determine the rate of a positive preoperative antibody screen in women who underwent apical POP surgery. METHODS: This was a retrospective cohort study of women who underwent apical POP surgery by 3 different routes: abdominal (abdominal sacrocolpopexy), robotic (robotic sacrocolpopexy), or vaginal (uterosacral or sacrospinous ligament fixation). RESULTS: Among 610 women who underwent apical POP surgeries between May 2005 and May 2016, 24 women (3.9%) received a perioperative blood transfusion. The rate of transfusion was higher in the abdominal group (11.1%) compared with robotic (0.5%, P < 0.001) and vaginal (0.5%, P < 0.001). In a logistic regression model, abdominal route of POP surgery remained significantly associated with transfusion (odds ratio, 20.7; 95% confidence interval, 2.7-156.6). Among the 572 women who had a preoperative T&S performed, 9 (1.5%) had a positive antibody screen. CONCLUSIONS: Blood transfusion was significantly more common in abdominal compared with robotic and vaginal apical POP surgeries. The rate of a positive antibody screen was low, suggesting that type O blood is low risk if cross-matched blood is not available. Thus, it may be reasonable to not order a preoperative T&S prior to robotic or vaginal apical POP surgery.

Concomitant Sacral Neuromodulation and Gynecologic Surgery: A Single-Institution Experience.

AIMS: Sacral Neuromodulation (SNM) is a safe and minimally invasive treatment for urinary and fecal pelvic floor disorders (PFDs). With a high prevalence of women reporting multiple PFDs, knowledge regarding concomitant surgery may inform optimal patient care. Our literature search did not identify any published data on this topic, thus we sought to report our experience with concomitant SNM and gynecologic surgery. Our primary objective was to identify the rate of adverse events among cases. Secondarily, we reviewed the anesthetics used to identify potential associations when performing combined surgery. MATERIALS AND METHODS: This was retrospective case series of women undergoing SNM at a single academic center from 2012 to 2018. Cases were identified using current procedural terminology codes for SNM and common gynecologic procedures. These electronic medical records were reviewed to identify cases that occurred concomitantly in addition to obtaining demographics, adverse events, type of anesthesia, and overnight hospital stay. Descriptive data analysis was performed with Excel. RESULTS: Of 200 identified cases of SNM, 15 (7.5%) were concomitantly performed with another procedure. Most concomitant surgeries occurred with insertion of implantable pulse generator. Three minor adverse events occurred: two urinary tract infections and one occurrence of urinary retention. Eight (53%) cases were performed under general anesthesia while seven (46%) received monitored sedation. CONCLUSIONS: No serious adverse events or anesthesia-related complications were identified in this series. While general anesthesia was used more often, it was in accordance with our standard practice for the gynecologic procedures. This study supports the safety of concomitant gynecologic and SNM surgery.

Lidocaine Use in Vaginal Surgery and Risk of Toxicity.

OBJECTIVES: The primary objective of this study was to compare the amount of lidocaine administered for vaginal reconstruction with versus without hysterectomy. The secondary objective was to assess the risk of lidocaine toxicity. METHODS: This retrospective cohort study compares lidocaine dose in 2 cohorts: women who underwent vaginal hysterectomy with additional vaginal reconstruction (VH + VR) versus those who underwent vaginal reconstruction without hysterectomy (VR only). Total intraoperative lidocaine dose included the intravenous dose from anesthesia and the vaginally injected dose from the surgeon. The risk of toxicity was defined as total dose greater than 7 mg/kg. The primary outcome was the difference in total lidocaine dose for VH + VR versus VR only. RESULTS: Among 372 women included, 140 (37.6%) were in the VH + VR group, and 232 (62.4%) in the VR-only group. For the primary outcome of total lidocaine dose between groups, VH + VR received more total lidocaine than did VR only (228 ± 105 vs 168 ± 78 mg, P < 0.001). This difference was due to the vaginal lidocaine dose (P < 0.001), with no significant difference in the intravenous lidocaine dose (P = 0.68). In a logistic regression model controlling for age, anesthesia type, sling, and anterior repair, posterior repair, and anesthesia type, VH remained an independent risk factor for increased lidocaine dose (P < 0.001). Two women received a toxic dose of lidocaine, and both were in the VH + VR group. CONCLUSIONS: Women undergoing vaginal hysterectomy with additional vaginal reconstructive procedures are more likely to receive a higher dose of lidocaine compared with women undergoing vaginal reconstruction alone. The risk of lidocaine toxicity is increased with concomitant procedures.

Evaluation of Opioid Prescriptions After Urogynecologic Surgery Within a Large Health Care Organization: How Much Are We Prescribing?

OBJECTIVES: Data regarding postoperative opioid prescriptions for patients undergoing urogynecologic surgery are sparse. Our objective was to quantify surgeon prescribing patterns for patients undergoing surgery for pelvic organ prolapse or stress urinary incontinence. METHODS: Patients who underwent surgery for pelvic organ prolapse or SUI within a large health care maintenance organization were identified by procedural codes within the electronic medical record. Medical records were reviewed for demographic and clinical data. Our primary objective was to describe initial postoperative morphine milligram equivalent (MME) dosages for patients undergoing various urogynecologic surgeries. Secondary objectives were to evaluate rates of postoperative non-opioid analgesic prescriptions, presence of additional postoperative opioid prescriptions within 90 days of surgery, and to characterize prescribing patterns of surgeons from different specialties. RESULTS: We evaluated 855 patients undergoing 7 urogynecologic surgeries. There was wide variation in the quantity of MME prescribed to patients undergoing different urogynecologic surgeries, and the mean MME ranged from 137.6 mg after a colpocleisis to 214.1 mg after a laparoscopic uterosacral ligament suspension. Less than two thirds of patients received a postoperative nonsteroidal anti-inflammatory drug (NSAID) prescription, and rates of NSAID prescriptions varied widely between surgeons from different specialties. Thirty-nine (4.6%) patients received an additional postoperative opioid prescription specifically for the indication of persistent postoperative pain. CONCLUSIONS: There is wide variation in the range of MME prescribed postoperatively to patients undergoing common urogynecologic surgeries. Less than two thirds of patients received a postoperative NSAID prescription, which was found to be independently associated with a higher postoperative opioid prescription dose.

Analysis of Robotic Procedural Times Using Colpassist Versus End-to-End Anastomosis Sizer for Robotic-Assisted Sacrocolpopexy: A Randomized Controlled Trial.

OBJECTIVE: The impact of vaginal instrumentation on operative time for robotic-assisted sacrocolpopexy (RSC) is not well understood. Colpassist (Boston Scientific, Quincy, Mass) is a vaginal positioning device designed to improve exposure with a curved double-sided handle that can be adapted to patient anatomy with 2 different sized functional ends. We sought to compare operative time for RSC using a Colpassist compared with a traditional end-to-end anastomosis sizer (EEAS). METHODS: This was a single-center randomized controlled trial of consecutive women undergoing RSC for apical pelvic organ prolapse. Participants were randomized to undergo RSC using either Colpassist or EEAS. The primary outcome was total operative time for the steps of RSC requiring use of a vaginal positioning device. Secondary outcomes included injury rates and satisfaction of the participants. RESULTS: Fifty-two women were enrolled (25 Colpassist, 27 EEAS). For the primary outcome, there was no significant difference in total operative time between procedures performed with Colpassist versus EEAS (P = 0.15). However, 16 (64%) of the 25 Colpassist arm versus 0 of EEAS (P < 0.01) required use of an alternative vaginal positioning device intraoperatively. Comparing secondary outcomes, there were no differences in rate of intraoperative injury between groups. Surgeon and fellow satisfaction scores were lower with Colpassist (P < 0.01). Surgical vaginal assistants were equally satisfied with both vaginal positioning devices (P > 0.05). CONCLUSIONS: Colpassist is a potential alternative to EEAS with no significant difference in operative time or complication rate. However, case completion with Colpassist was significantly lower than EEAS and was associated with lower surgeon and fellow satisfaction.

Predictors of Opioid Administration in the Acute Postoperative Period.

OBJECTIVES: Our primary objective was to evaluate age as a predictor of postanesthesia care unit (PACU) opioid administration in women undergoing reconstructive pelvic surgery. Our secondary objective was to identify additional predictors of PACU opioid administration. METHODS: We conducted a retrospective cohort study of women undergoing outpatient urogynecologic surgery for pelvic organ prolapse and/or stress urinary incontinence between September 2015 to October 2016 at 1 academic medical center. We compared 2 cohorts (1) women older than 65 years and (2) women older than 65 years. Our primary outcome was any opioid medication administered during the PACU admission. RESULTS: A total of 183 women were included in the study; 124 (68%) were younger than 65 years, and 59 (32%) were 65 years or older. For our primary outcome, women younger than 65 years were more likely to be given any opioids in PACU than women 65 years (70% vs 54%, P = 0.04, respectively). Women younger than 65 years were also given higher total amounts of opioid narcotics postoperatively (9.0 ± 8.3 vs 5.1 ± 6.0 mg, P < 0.05). For our secondary outcome, we found that PACU opioid administration was associated with midurethral sling (MUS) surgery (70% MUS vs 30% no MUS, P = 0.04) and high maximum PACU pain score (97% high vs 3% low, P < 0.01). CONCLUSIONS: In women undergoing urogynecologic surgery, age younger than 65 years is a predictor of high PACU pain score and resultant PACU opioid dispensation. This population should be targeted in future studies addressing the use of nonopioid multimodal therapies in the treatment of postoperative pain.

Association of Anticholinergic Risk Score With Functional Status in Patients Preparing for Pelvic Reconstructive Surgery.

OBJECTIVES: Anticholinergic medication use has been associated with cognitive impairment and other functional limitations, particularly in older patients. The anticholinergic risk score (ARS) can be used to measure a patient's cumulative exposure to medications with anticholinergic properties. Our primary objective was to evaluate the correlation between ARS and functional status, as measured by instrumental activities of daily living (IADL), in patients preparing to undergo urogynecologic surgery. The secondary objective was to examine the correlation between ARS and physical function in this same cohort. METHODS: This was a planned cross-sectional analysis of a prospective cohort study to evaluate the impact of urogynecologic surgery on functional status. The ARS was calculated by summing the ARSs of each patient's medications and classified as high (ARS > 5) or low (ARS ≤ 5). A patient's ability to live independently was determined using the IADL questionnaire. The patient's physical function status was determined using the functional comorbidity index. RESULTS: One hundred twenty-two patients were evaluated. A total of 89.3% of subjects had a low and 10.7% had a high ARS score. For our primary outcome, high ARS was associated with low IADL in logistic regression controlling for age and formal education level (odds ratio, 8.0; 95% confidence interval, 1.4-46.9). For our secondary outcome, ARS was not associated with the functional comorbidity index (P = 0.24). CONCLUSIONS: These data support recognition of ARS as a potential risk factor for low functional status in patients planning urogynecologic surgery.

Workforce Analysis of Female Pelvic Medicine and Reconstructive Surgery, 2015 to 2045.

OBJECTIVES: The aim of this study was to assess how the projected increase in prevalence of pelvic floor disorders (PFDs) will impact the number of patients per female pelvic medicine and reconstructive surgery (FPMRS) subspecialist between 2015 and 2045. METHODS: We performed a workforce analysis of FPMRS subspecialists in the United States by developing a model to predict the number of FPMRS subspecialists in 5-year increments from 2015 to 2045. Our model allowed for selection of the number of current FPMRS subspecialists, the number and sex of new FPMRS subspecialists added per year, and retirement age of FPMRS subspecialists. The number of women with PFDs from 2015 to 2045 was then predicted by applying published, age-specific prevalence rates to the 2012 US Census Projections for women aged 20 years or older. For our primary outcome, we divided the projected number of patients by the projected number of FPMRS subspecialists every 5 years from 2015 to 2045. RESULTS: The model predicts the number of FPMRS subspecialists will increase from 1133 to 1514 with a sex shift from 46% female to 81% female between 2015 and 2045. The number of women with ≥1 PFD is predicted to increase from 31.4 million in 2015 to 41.9 million in 2045. For our primary outcome, the number of patients per FPMRS subspecialist is projected to range from 27,870 in 2015 to 27,650 in 2045. CONCLUSIONS: The current ratio of patients per FPMRS subspecialist appears high and is predicted to remain near current levels over the next 30 years. These projections support the need for continued training of physicians skilled in treating PFDs.

Risk Factors for Surgical Site Infection in Patients Undergoing Sacral Nerve Modulation Therapy.

OBJECTIVES: The aim of this study was to identify risk factors for surgical site infection in patients undergoing sacral nerve modulation (SNM) surgery. METHODS: We conducted a retrospective cohort analysis of 290 patients undergoing a total of 669 SNM procedures between 2002 and 2012 by 2 fellowship-trained female pelvic medicine and reconstructive surgery attending physicians at the University of California-Irvine Medical Center. Infection was defined as a charted abnormal examination finding at the implantation site (erythema, induration, purulent discharge) resulting in prescription of antibiotics, hospitalization, or explantation. We extracted information from the medical record regarding possible risk factors for infection including age, body mass index, immunosuppression (diabetes mellitus, chronic steroid use, smoker, chemotherapy), number of procedures per patient, and number of days between stages 1 and 2. In addition, we compared infection rates before and after 2008 when a clinical practice change was made with the implementation of home chlorhexidine washing (CHW) prior to SNM surgery. RESULTS: Thirty infections occurred, 25 of which were managed with oral antibiotics. Nine required intravenous antibiotics, and 11 required removal of the implanted device. Three patients experienced infection on 2 separate occasions. Seventeen infections had culture data available. Nine of the patients who underwent explantation had wound cultures positive for methicillin-resistant Staphylococcus aureus.Thirteen of the 26 patients who developed infection had medical histories significant for immunosuppression. Three patients developed late-onset abscess formation at 234, 257, and 687 days after stage 2, respectively. The median time between the most recent SNM procedure and development of infection was 14 days (range, 6-88 days).Body mass index and immunosuppression were significant predictors of infection, whereas age, parity, indication for procedure, and number of days between stages 1 and 2 were not found to be independent predictors. Three hundred twenty-three procedures were performed prior to and 346 procedures were performed after institution of home CHW. Twenty-four (80%) of the 30 reported infections were prior to CHW, whereas only 6 infections (20%) occurred after this change in practice. Prior to institution of CHW, the infection rate was 7.4%, and after institution of CHW, it was 1.7% (P = 0.002). Of the 83 patients with compliance data available for CHW use, 71 reported using CHW, whereas 12 reported not using CHW. CONCLUSIONS: Surgical site infection is a significant risk of SNM surgery, although our infection rate is lower than previously reported. Chlorhexidine washing appears to reduce the risk of infection in this population. Because the majority of infections requiring explantation were methicillin-resistant S. aureus positive, prophylactic treatment for this organism should be considered as an additional strategy to reduce infection. Body mass index and immunosuppression appear to be independent risk factors for infection.

Comparison of location of mesh placed transvaginally vs mesh placed abdominally at the time of sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The location of mesh placed at the time of abdominal sacrocolpopexy (ASC) is hypothesized to be in the same location histologically as mesh placed via full-thickness vaginal dissection in a cadaver model. METHODS: Ten fresh frozen cadavers underwent mesh placement via traditional ASC. In the same specimen, a transvaginal mesh (TVM) procedure was performed, attempting a full-thickness dissection. A block section was excised from each area including full thickness of the vagina and bladder with the intervening mesh. This was analyzed by a blinded pathologist. RESULTS: All cadavers underwent successful placement of both transabdominal mesh and TVM. Of the abdominally placed meshes, 6 were located between the vagina and bladder, whereas 3 were situated within the vaginal wall, with an average depth of 0.30 mm. Five of the vaginal mesh pieces were placed between the bladder and vagina, and 4 within the vaginal wall at a depth of 0.25 mm. One specimen placed vaginally was 0.05 mm within the serosa of the bladder. One specimen could not be interpreted, despite multiple cuts. CONCLUSION: ASC and full-thickness vaginal dissection result in histologically similar locations. Dissection for ASC may only result in the correct plane between the bladder and vagina in approximately 60 % of cases. We achieved full-thickness dissection for the transvaginal approach in 50 % of the cases, with one small penetration into the bladder serosa. Using a full-thickness dissection technique for TVM may be one way of reducing mesh exposure rates in those seen with ASC.

Finding a needle in a haystack: Ultrasound guided extraction of a sewing needle from the perineum.

•Self-insertion of foreign bodies for sexual gratification is on the rise.•The consequences of foreign bodies insertion can be life-threatening.•Insertion sites of foreign bodies can be difficult to visualize depending on location.•Difficult extractions can be performed in the operating room by a specialist.•Intra-operative ultrasound can help in extracting foreign bodies.

Toll-like receptor 8: augmentation of innate immunity in platinum resistant ovarian carcinoma.

Ovarian cancer is the most deadly gynecologic cancer, with 15,000 anticipated deaths within the United States alone in 2012, and new treatment strategies are needed. Ovarian cancer tumors are known to host an immunosuppressive microenvironment. This suppression may be reversible via activation of the innate immune response. Toll-like receptor 8 activates innate immunity while simultaneously inhibiting the effects of regulatory T cells within the ovarian cancer tumors. VTX-2337 is a novel small molecule ligand of Toll-like receptor 8 and is currently the subject of a Phase II randomized, double-blind, placebo-controlled trial Gynecologic Oncology Group (GOG)-3003 for patients with recurrent platinum-resistant ovarian cancer. We look forward to the results of this trial as support for the paradigm of process therapy in the treatment of ovarian cancer.

Outside slide review in gynecologic oncology: impact on patient care and treatment.

In gynecologic oncology, surgical and adjuvant therapy rely heavily on correct pathologic diagnosis. Thus, in-house review of outside pathologic slides and specimens has become routine within large tertiary referral centers. We sought to determine the impact of outside pathologic slide review on gynecologic oncology patient care and treatment. Gynecologic oncology cases between January 2007 and January 2012 were evaluated. Clinical information was gathered from comprehensive chart reviews and reports created after multidisciplinary treatment planning conferences. Discrepancies in diagnosis were identified as major if they resulted in a treatment alteration and minor if they did not impact care. Data were analyzed using descriptive statistics and the Fisher exact test. A total of 279 cases were identified and reviewed as part of the study--126 (45.2%) biopsy/cytology specimens and 153 (54.8%) surgical excision specimens. Minor discrepancies were noted in 25 reviewed cases (9%) and major discrepancies in 19 cases (6.8%). Among those patients in whom management was changed based on specialized pathologic review, 50% underwent additional surgery, 16% had their surgical plan modified, and 16% received adjuvant treatment or had their adjuvant treatment modified. In 235 cases (84.2%), institutional rereview of the outside slides/specimens did not result in a change in diagnosis. Diagnostic discrepancies were evenly distributed across all primary sites evaluated. The cost of outside pathologic review was estimated at $2,936 US dollars per change in diagnosis. Mandatory slide review in gynecologic oncology is important and results in diagnostic changes in approximately 16% of cases, with 43% of those changes impacting treatment.