Morbidity associated with posterior intravaginal slingplasty for uterovaginal and vault prolapse.

OBJECTIVE: This study was carried out to evaluate the safety and efficacy of posterior intravaginal slingplasty (IVS) for upper genital prolapse. SETTING: Gynaecology Department, Benenden Hospital, Kent, UK. MATERIALS AND METHODS: An observational study was conducted on 127 women, who underwent posterior IVS using the IVS Tunneller (Tyco HealthCare, USS, Norwalk, CT, USA). The indications for surgery were uterovaginal prolapse in 65% and vault prolapse in 35%. Patient follow-up was at 6 weeks, 6 months, 1 year and annually thereafter. RESULTS: In addition to posterior IVS, hysterectomy was performed in 22 patients, anterior colporrhaphy in 63 patients and transobturator mid-urethral tape insertion in eight patients. The mean operating time was 46 +/- 18.5 min and for posterior IVS alone was 27.4 +/- 10 min, and the mean peri-operative drop in haemoglobin level was 1.4 +/- 0.75 gm/dL. There were no rectal, vesical or ureteric injuries. After a mean follow-up of 14 months (range 2-26 months), upper genital support was maintained in 88%, cystocele formation occurred in 8% and recurrent rectocele was seen in 11%. There was a 17% risk of tape erosion (21/127) and a re-operation rate of 24% (30/127). The risk of tape erosion was related to patient age above 60 years (RR = 1.6, 95% CI 1.02-2.5) and current treatment for diabetes (RR = 4, 95% CI 1.7-9.2). Parity, body mass index, menopausal status, HRT use, hysterectomy and surgeon's experience were not found to influence tape erosion rate. CONCLUSION: Posterior intravaginal slingplasty is a minimally invasive procedure for upper genital prolapse with an acceptable success rate. However, the operation is associated with high vaginal erosion and re-operation rates.

Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trial.

OBJECTIVE: To assess the safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles during vaginal hysterectomy in comparison with the conventional method of securing the pedicles by suture ligation. DESIGN: Randomised controlled trial. SETTING: Gynaecology Department, Benenden Hospital, Kent. POPULATION: One hundred and sixteen women undergoing vaginal hysterectomy were prospectively randomised to either LigaSure (Group I) or suture ligation (Group II) for securing the pedicles. METHODS: Data of patients were collected prospectively. Statistical analysis was performed using the Mann-Whitney U test, chi(2) and Fisher's exact test as appropriate. MAIN OUTCOME MEASURES: Operating time, operative blood loss and peri-operative complications. RESULTS: The operating time was significantly shorter in the LigaSure group compared with the control group (P < 0.04). There was no statistical significant difference between the two groups in operative blood loss (P= 0.433), but peri-operative haemorrhagic complications were less frequent in the LigaSure group (0%vs 6.8%, P= 0.057). Four patients in the control group required either conversion to laparotomy because of bleeding, return to theatre for immediate post-operative haemorrhage or readmission for vault haematoma, whereas none in the LigaSure group had bleeding from unsecured pedicles. CONCLUSION: The LigaSure vessel sealing system is a safe alternative for securing pedicles in vaginal hysterectomy when compared with conventional suture ligation. Larger studies are required to determine its place in gynaecological surgery.

Vaginal endoscopic oophorectomy with vaginal hysterectomy: a simple minimal access surgery technique.

The main advantage of laparoscopic assisted vaginal hysterectomy (LAVH) is ease of access to the ovaries; despite this, LAVH is infrequently performed due to the inherent difficulty of the technique. Lower morbidity, shorter length of surgery, reduced hospital stay and more rapid recovery are the main advantages of vaginal hysterectomy, but one of its limitations is the accessibility of the ovaries. Three methods of vaginal endoscopic oophorectomy following vaginal hysterectomy are described in this paper. Endoscopic vaginal oophorectomy was successfully performed during 82 cases of vaginal hysterectomy and the results show that the technique is simple, safe and easy to learn, and an alternative to laparotomy and LAVH in the absence of pelvic adhesions.

Induction of labour with vaginal prostaglandin E2 pessaries.

Wax-based pessaries, each containing 3 mg of prostaglandin E2 (PGE2), were administered intravaginally for the induction of labour. The induction to delivery intervals were shorter than those in a control group induced by amniotomy and intravenous oxytocin. There was a remarkable reduction in the Caesarean section rate from 12 per cent in the control group to 2.4 per cent in the study group in primiparae, and from 8 per cent to 1.6 per cent in multiparae. Side effects associated with the PGE2 were rare, as were complications.

Vaginal subtotal hysterectomy and sacrospinous colpopexy: an option in the management of uterine prolapse.

Interest in vaginal hysterectomy is rising. Controversy remains regarding the value of conservation of the cervix at hysterectomy. Subtotal vaginal hysterectomy is a simple procedure that carries a low risk of morbidity. In combination with sacrospinous fixation it can be an option in the management of patients with marked uterine prolapse who desire retention of the cervix. The technique is described, and a case is reported.

Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: an evolving concept.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of the performance of sacrospinous cervicocolpopexy with uterine conservation in the treatment of uterovaginal prolapse in women over the age of 60 years. STUDY DESIGN: This was a nonrandomized prospective controlled study. Between February 1996 and January 2001, 109 women above the age of 60 years with a complaint of symptomatic uterovaginal prolapse were treated with either sacrospinous cervicocolpopexy with uterine conservation or vaginal hysterectomy concomitant with sacrospinous colpopexy. Patients were reviewed at 6 weeks and 6 and 12 months after operation and then yearly thereafter. Preoperative patient characteristics, operative, and postoperative events and follow-up results were recorded. RESULTS: During the study period, 61 patients (56%) underwent sacrospinous cervicocolpopexy with uterine conservation (group A), whereas 48 patients (44%) had vaginal hysterectomy performed concomitantly with sacrospinous colpopexy (group B). The mean age for the two groups was comparable (70.1 +/- 6 years vs 69.4 +/- 4.6 years, respectively; P =.8). Group A had significantly less blood loss (P <.01), shorter operating time (P <.01), and fewer complications after surgery (P =.01) compared with group B. After a mean follow-up period of 33 and 34 months, respectively, the two groups had comparable success rates with regard to uterine and upper vaginal support (93.5% and 95.9%, respectively; P =.6). Recurrent cystocoele developed in 11.4% and 10.4% of groups A and B, respectively (P =.9). Within the follow-up period, 3 patients (5%) in group A and 2 patients (4.2%) in group B underwent repeat operation for recurrent uterovaginal or vault prolapse. CONCLUSION: Sacrospinous cervicocolpopexy with uterine conservation is a safe and effective surgical option that could benefit elderly patients with uterovaginal prolapse. It avoids the potential morbidity of vaginal hysterectomy and is associated with a high success rate.

The national maternal mortality study of Egypt 1992-1993.

The study was designed as a population-based sample of all maternal deaths over a one-year period in 21 governorates. A sample of 7487 deceased women of reproductive age was selected. During pregnancy, delivery, or in the puerperium, there were 825 772 maternal deaths and 53 from incidental causes. Of the maternal deaths, 69.5% were due to direct obstetric causes while 26.9 and 3.6% were due to indirect and unknown causes, respectively. The national maternal mortality ratio was 174 maternal deaths per 100 000 live births.

Sacrospinous colpopexy at vaginal hysterectomy: method, results and follow up in 75 patients.

This study reviews our experience with sacrospinous colpopexy done at the time of vaginal hysterectomy over a period of 3 years, and discusses the indications, outcome and safety of the technique. Between January 1996 and December 1998, 75 patients had sacrospinous colpopexy at the time of vaginal hysterectomy. The mean age of patients was 57.1 years. Simultaneous bilateral vaginal oophorectomy was done in 36 patients, anterior colporrhaphy in 56, and posterior colporrhaphy in 24. All patients underwent perineorrhaphy. Dissection and obliteration of the enterocoele sac was performed whenever encountered. Patients were seen at 2, 6 and 12 months following surgery and then yearly thereafter. The mean operative time was 85 minutes, mean uterine weight was 101 grams and mean blood loss was 137 ml. The mean follow-up period was 15 months. The vaginal vault remained well supported in 96.7%, with recurrent cystocoele in six patients (9.8%), recurrent rectocoele in 1.3%, and shortvagina in 3.3%. At 1-year follow up, 28% of those who were sexually active prior to surgery reported an improvement in sexual function. When dealing with uterovaginal prolapse, sacrospinous colpopexy performed at the time of vaginal hysterectomy is an effective treatment option for vaginal vault support.

Refining surgical technique to prevent occurrence of vault haematoma after vaginal hysterectomy.

We set out to analyse the effect of refinement of incision and closure technique of the vaginal vault on the incidence of vault haematoma after hysterectomy. All the surgery was performed in the Gynaecology Department, Benenden Hospital, Kent, UK. This was initially a retrospective study followed by a prospective analysis of postoperative morbidity related to vaginal vault haematomas and critical review of surgical technique over 5 years in all cases undergoing vaginal hysterectomy within our unit. Following refinement in surgical technique a significant reduction in the incidence of clinically significant vaginal vault haematomas from 15.7% to 1.7% (P<0.001) was observed over a 4-year period. Adoption of the described surgical techniques is recommended to minimise the risk of clinically significant vaginal vault haematomas after vaginal hysterectomy.