Effect of Scopolamine Patch Use on Postoperative Voiding Function After Transobturator Slings.

OBJECTIVES: The aim of this study was to determine whether the use of a preoperative transdermal scopolamine (TDS) patch for postoperative nausea and vomiting prophylaxis affects the success of a voiding trial after a transobturator tape sling procedure. METHODS: This study is a retrospective cohort study of adult women who underwent a transobturator tape sling procedure without concomitant procedures from February 1, 2009 through August 1, 2010. The exposed group included all eligible women who received a preoperative TDS patch. For each exposed woman, we selected the next 2 consecutive eligible women who did not receive a TDS patch to be included in the unexposed group. The primary outcome was postoperative voiding trial failure. RESULTS: We identified 35 women who met eligibility criteria and used a preoperative TDS patch, and included 70 women who did not use a preoperative TDS. A significantly higher proportion of women in the TDS patch group (54.3%) failed their voiding trial than in the group that did not receive TDS (7.1%, P ≤ 0.001). A history of an incontinence procedure, older age, and higher body mass index strengthened the association between TDS patch and voiding trial failure. The adjusted model yielded a risk ratio for voiding trial failure of 13.8 (95% confidence interval, 5.2-36.5) for women who received TDS patch compared with those who did not. CONCLUSIONS: The results of this study demonstrate that use of TDS patches for postoperative nausea and vomiting prophylaxis may negatively affect the success of voiding trials after transobturator tape sling procedures.

Sacral osteomyelitis after laparoscopic sacral colpopexy performed after a recent dental extraction: a case report.

BACKGROUND: Sacral osteomyelitis and subsequent discitis is a rare complication after laparoscopic sacral colpopexy to repair apical vaginal prolapse. CASE: We present a patient who developed Bacteroides fragilis sacral osteomyelitis and discitis after laparoscopic sacrocolpopexy with synthetic monofilament mesh and sacral titanium coil fixation. The patient had undergone dental extraction of 3 infected teeth approximately 2 weeks before sacrocolpopexy for stage IV apical vaginal prolapse. Computed tomography and magnetic resonance imaging (MRI) confirmed sacral osteomyelitis and discitis along with Bacteroides fragilis bacteremia approximately a week and a half after the original surgery. The patient was followed up with serial MRIs of the spine which revealed degeneration at the sacral promontory. The patient underwent successful removal of the entire mesh and sacral titanium coils with resolution of her symptoms. Follow-up MRI of the spine revealed resolution of her sacral osteomyelitis. CONCLUSIONS: Sacral osteomyelitis is a rare complication after sacrocolpopexy for pelvic organ prolapse repair. There should be a high index of suspicion for patients presenting with disproportionate low back pain and vague symptoms after surgery. Recent oral surgery may increase the risk of bacteremia and subsequent infectious morbidity after sacrocolpopexy with the use of synthetic mesh for prolapse repair.

Body image, regret, and satisfaction following colpocleisis.

OBJECTIVE: Colpocleisis is a definitive surgical treatment for prolapse resulting in vaginal obliteration. We sought to evaluate body image, regret, satisfaction, and pelvic floor symptoms following this procedure. STUDY DESIGN: This was a prospective multicenter study through the Fellows' Pelvic Research Network. All women electing colpocleisis for management of pelvic organ prolapse were screened for enrollment. The Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory, and the modified Body Image Scale (BIS) were completed preoperatively and 6 weeks following surgery. Additionally, the Decision Regret Scale and the Satisfaction with Decision Scale were administered at the 6-week postoperative visit. A sample size of 88 subjects was calculated to evaluate change in the BIS score. RESULTS: In all, 87 patients were analyzed. Mean age was 79 years (SD 5.8) with a mean body mass index of 27 (SD 5.3). The majority (89.3%) was Caucasian. Six weeks after surgery, significant improvements were noted in all parameters. Mean BIS scores decreased from 4.8 to 1.2 (P < .001), signifying improved body image. Indeed, the overall number of subjects with BIS scores in the normal range doubled after surgery. Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores decreased significantly (P < .001 and P < .001), suggesting a positive impact on bladder, bowel, and prolapse symptoms. Finally, low levels of regret (mean score 1.35) and concurrent high satisfaction (mean score 4.73) were documented. CONCLUSION: Colpocleisis improves body image and pelvic floor symptoms while giving patients a definitive surgical option that results in low regret and high satisfaction.

Laparoscopic supracervical hysterectomy with transcervical morcellation and sacrocervicopexy: initial experience with a novel surgical approach to uterovaginal prolapse.

The objective of this retrospective study was to evaluate the feasibility, safety, and efficacy of a new laparoscopic technique for the treatment of uterovaginal prolapse using a transcervical access port to minimize the laparoscopic incision. From February 2008 through August 2010, symptomatic pelvic organ prolapse in 43 patients was evaluated and surgically treated using this novel procedure. Preoperative assessment included pelvic examination, the pelvic organ prolapse quantification scoring system (POP-Q), and complex urodynamic testing with prolapse reduction to evaluate for symptomatic or occult stress urinary incontinence. The surgical procedure consisted of laparoscopic supracervical hysterectomy with transcervical morcellation and laparoscopic sacrocervicopexy with anterior and posterior mesh extension. Concomitant procedures were performed as indicated. All procedures were completed laparoscopically using only 5-mm abdominal port sites, with no intraoperative complications. Patients were followed up postoperatively for pelvic examination and POP-Q at 6 weeks, 6 months, and 12 months. The median (interquartile range) preoperative POP-Q values for point Aa was 0 (-1.0 to 1.0), and for point C was -1.0 (-3.0 to 2.0). Postoperatively, median points Aa and C were significantly improved at 6 weeks, 6 months, and 12 months (all p < .001). One patient was found to have a mesh/suture exposure from the sacrocervicopexy, which was managed conservatively without surgery. We conclude that laparoscopic supracervical hysterectomy with transcervical morcellation and laparoscopic sacrocervicopexy is a safe and feasible surgical approach to treatment of uterovaginal prolapse, with excellent anatomic results at 6 weeks, 6 months, and 12 months. Potential advantages of the procedure include minimizing laparoscopic port site size, decreasing the rate of mesh exposure compared with other published data, and reducing the rate of postoperative cyclic bleeding in premenopausal women by removing the cervical core. Longer follow-up is needed to determine the durability and potential long-term sequelae of the procedure.

Atypical presentation of a vaginal epithelial inclusion cyst.

Vaginal masses can have numerous different presentations and causes. Physicians can often make an empiric diagnosis of these masses on the basis of their clinical presentation and location. Most of these diagnoses are correct, with the rare exception of the occasional urethral diverticulum or hydrocele. In this case report, we discuss the initial diagnosis of a suspected infected Bartholin gland duct cyst that was in fact a 10 × 8 × 7.5-cm epithelial inclusion cyst that extended through the ischiorectal fossa and down to the gluteal region, requiring extensive dissection. Also presented is a detailed description of the anatomical landmarks encountered at dissection through the vaginal sidewall and ischiorectal fossa.

Assessment of women with defecatory dysfunction and manual splinting using dynamic pelvic floor magnetic resonance imaging.

OBJECTIVE: This study aimed to describe magnetic resonance imaging (MRI) findings in women with defecatory dysfunction who perform manual splinting. METHODS: This is a retrospective study of 29 patients from a single urogynecology center who presented with complaints of defecatory dysfunction and who reported manual splinting to assist with bowel movements. Patients were scheduled for an MRI study with a novel "splinting" protocol to evaluate the effects of their manual splinting on the pelvic floor. The protocol involved asking patients to splint during the MRI, as they normally would when trying to defecate. The goal was to evaluate any change in pelvic anatomy and compensation for an anatomic defect that could potentially lead to their defecatory dysfunction. Magnetic resonance images of the pelvis were obtained at rest, with pelvic floor contraction, with Valsalva, and during manual splinting. These images were then reviewed by radiologists who evaluated various parameters, including anorectal angle, levator ani muscle integrity, and the presence of rectocele, cystocele, apical prolapse, and enterocele. The external and internal anal sphincters were also evaluated for continuity. RESULTS: From September 2008 to October 2010, 29 women reported defecatory dysfunction and the need for manual splinting. Their mean (SD) age was 55.2 (10.5) years. Magnetic resonance images showed a rectocele in 86.2% of the study group, cystocele in 75.9%, enterocele in 10.3%, and a defect of the levator ani muscles in 17.2%. Twenty-one (72.4%) women had more than 1 of these defects. In addition, 27.6% had an anorectal angle less than 90 degrees or greater than 105 degrees.Patients in the study group splinted in the vagina (58.6%), on the perineum (31.0%), or on the buttock (10.3%). In all but 1 woman (96.6%), splinting improved or completely corrected the identified defect(s) as evidenced with MRI. Among those who used vaginal splinting, 52.9% of defects were corrected and 47.1% were improved. Perineal splinting corrected 55.6% and improved 33.3% of cases and was ineffective in 11.1% of cases, whereas buttock splinting corrected 33.3% and improved 66.7% of cases. CONCLUSIONS: Most women in our study group who used manual splinting to assist in defecation are compensating for a pelvic floor defect that can be detected on MRI. Magnetic resonance imaging of the pelvis may help elucidate the etiology of the defecatory dysfunction in some women and may assist pelvic reconstructive surgeons in planning surgical correction of pelvic floor defects. Magnetic resonance imaging may also identify defects in the pelvic floor that are, at the present time, not amenable to surgical correction.

Ureteral injury due to a Harmonic scalpel during laparoscopic salpingo-oophorectomy.

We present an unusual complication of a ureteral injury occurring during a bilateral laparoscopic salpingo-oophorectomy with the Harmonic scalpel (HS). The case illustrates in the same patient the versatility of the HS as a laparoscopic surgical instrument and energy source while at the same time demonstrating the potential for adverse, unexpected complications.

Atypical graft infection presenting as a remote draining sinus.

BACKGROUND: Synthetic materials are being used increasingly in reconstructive pelvic surgery. Multifilament polypropylene mesh in particular has been associated with healing abnormalities and other postoperative complications. This article describes an atypical infection presenting as a draining sinus tract to the lower extremity after intravaginal slingplasty. CASE: An otherwise healthy 75-year-old-woman presented with recurrent leg cellulitis 18 months after posterior intravaginal slingplasty for vaginal vault prolapse. A 35-cm fistulous tract draining from the pelvis to the lower thigh was identified. The patient underwent surgical debridement and was treated with 12 weeks of intravenous antibiotics with complete healing and no recurrence of symptoms. CONCLUSION: Complications associated with the multifilament mesh used in the intravaginal slingplasty tunneler device include pain, erosion, localized abscess, and genitourinary fistula.