Twelve years' experience with fascia lata autograft to replace complicated anterior vaginal mesh.

OBJECTIVES: To report 12-year experience with replacing transvaginal mesh (TVM) with fascia lata autograft. METHODS: This was a chart review of TVM removal and replacement with a fascia lata autograft placement by a single surgeon between 2005 and 2017. The Pelvic Organ Prolapse Quantification (POP-Q) system before and 1 year following the procedure, patient-reported recurrence of symptoms, changes in the POP-Q examination and complication rates are analyzed. RESULTS: Twenty-four patients were included. Mean age was 57.2 (95% CI 53.2-61.2) years. Mean number of days to Foley catheter removal was 3.2 days (95% CI 1.6-4.9) and mean number of days to drain removal was 10.9 days (95% CI 9.9-12.0). Following the surgery, no leg seroma, infection or numbness was reported. UTI occurred in four (16.7%) of the participants postoperatively. At 3-month follow-up, mild urinary symptoms were reported in five participants (20.8%). At 1-year follow-up, one participant was symptomatic of pelvic organ prolapse. Paired t-test analysis revealed statistically significant retraction of Aa and Ba vaginal points (p < 0.001). C, GH and PB points were also statistically significantly retracted. CONCLUSION: Fascia lata autograft for anterior compartment reconstruction due to TVM complications is associated with high safety and efficacy rates.

Ultrasound Indicators of Rectal Support Defect in Women With Obstructive Defecatory Symptoms.

OBJECTIVE: The anatomic and physiologic pathophysiology of obstructive defecatory symptoms is complex and poorly understood. As a consequence, there is no one surgical method that can achieve overall superiority. We aimed to investigate rectal architectural change in women with obstructive defecatory symptoms using three-dimensional pelvic floor ultrasound. METHODS: This retrospective cohort study included 65 women who were referred to our urogynecology clinic because of varied pelvic floor disorders between January 2013 and January 2014. Patients completed a standardized interview including PFDI-20 questionnaire and received a standard examination and assessment of pelvic floor by three-dimensional endovaginal ultrasound. Women were categorized to case and control based on their answers to questions 7, 8, and 14 on PFDI-20 (Colorectal and Anal Distress Index) questionnaire. In ultrasound images, levator plate descent angle, levator plate-probe distance, and rectal area have been measured and values have been compared among symptomatic and asymptomatic patients. RESULTS: Forty-five women with obstructive defecatory symptoms and 20 asymptomatic women entered the study. There was no significant difference in mean (SD) age (56.55 [SD] 13.29 vs 51.8 [15], P = 0.2), mean (SD) body mass index (27.39 [6.7] vs 24.2 [4.08], P = 0.11), and median (range) parity (3 [1-7] vs 2 [1-6], P = 0.15) among categories. There was significant difference in ultrasound measurements, levator plate descent angle, levator plate-probe distance, and rectal area, between women with obstructive defecatory symptoms and asymptomatic women. CONCLUSIONS: Women with obstructive defecatory symptoms have wider rectum and descendent levator plate regardless of the stage of prolapse as measured by POPQ or the severity of rectocele.

Shear Wave Elastography to Assess Perineal Body Stiffness During Labor.

OBJECTIVES: The objective of this study was to evaluate perineal body stiffness intrapartum using shear wave elastography ultrasound and to study its association with maternal and labor characteristics. METHODS: This was a prospective observational study. Pregnant women with term pregnancy who had been admitted for labor management were recruited into the study. Transperineal shear wave elastography of perineal body was performed. Maternal and labor data were retrieved from electronic medical charts. RESULTS: Thirty-two patients' data were available for analysis. Mean (SD) melastography modulus was 15.33 (5.49). While comparing the mean elastography modulus across maternal and labor characteristics, the difference was statistically different between parity, cervical dilation, and perineal laceration presence groups (P < 0.05). The mean of elastography modulus of primiparous women with cervical dilation less than 3 cm was 21.47 kPa, whereas that of multiparous women was 13.17 kPa (P = 0.0511). Perineal laceration was more prevalent in women with stiffer perineal body. The risk of having perineal laceration compared with no perineal laceration was 29.1% higher for each additional unit increase in perineal body elastography modulus (odds ratio, 0.709; 95% confidence interval, 0.507-0.992). CONCLUSIONS: Shear wave elastography can be used to quantify perineal body stiffness. Primiparous women in early stages of labor have stiffer perineal body than multiparous women in any stage of labor and primiparous women in late stage of labor.

Technique for Tissue Containment and Extraction in the Complex Minimally Invasive Myomectomy Setting.

STUDY OBJECTIVE: To achieve tissue containment and extraction for numerous and large myomas in the complex minimally invasive difficult myomectomy setting via a surgical tutorial including technical pointers and suggestions DESIGN: A step-by-step explanation of the .surgery using video (instructive video) (Canadian Task Force classification III). Institutional review board approval was not required for this study. SETTING: George Washington University Hospital, Washington, DC. PATIENTS: Multiple patients with a high number or large size of leiomyomata. INTERVENTIONS: Four reproducible techniques that enable the minimally invasive gynecologic surgeon to perform complex tissue containment and extraction: MEASUREMENTS AND MAIN RESULTS: One of the main challenges encountered with minimally invasive myomectomy procedures includes myoma containment and extraction. Given the potential risks for leiomyomatosis and the spread of leiomyosarcoma, the Food and Drug Administration banned electromechanical morcellation device usage [1]. After implementation of the ban and fueled by the increasing size and number of myomas removed through minimally invasive techniques, tissue containment and extraction are becoming increasingly challenging. This shift is partly reflected by the number of complications attributable to surgeon experience [2,3]. With the increase in the number of myomas removed during a minimally invasive myomectomy, the risk of myoma retention in the abdominal cavity is amplified. Also, the increase in the myoma size removed through minimally invasive surgery renders tissue extraction through contained, extracorporeal, manual morcellation more challenging [2-5]. Inefficiencies in tissue containment and extraction could potentially be hazardous to the patient's safety and detrimental to the operating room efficiency, and the AAGL Practice Report on tissue extraction emphasizes that the use of specimen retrieval pouches should be investigated further [2-6]. Patients underwent uncomplicated complex minimally invasive myomectomy. CONCLUSION: Mastering these reproducible techniques maximizes patient safety and operating room efficiency during minimally invasive myomectomy procedures.

Surgical variance between postconceptional and preconceptional minimally invasive transabdominal cerclage placement.

Recent data show that transabdominal cerclage placement via laparoscopy carries better obstetrical outcomes in comparison to transabdominal cerclage placement via laparotomy. In this surgical tutorial, we review the technique for minimally invasive abdominal cerclage and highlight the surgical differences between preconceptional and conceptional cerclage.