Impact of Severe Obesity on Major Perioperative Complications for Prolapse Surgery.

IMPORTANCE: Obesity adds complexity to the decision of surgical approach for pelvic organ prolapse; data regarding perioperative complications are needed. OBJECTIVE: The aim of the study was to evaluate associations of body mass index (BMI) and surgical approach (vaginal vs laparoscopic) on perioperative complications. STUDY DESIGN: Patients who underwent prolapse surgery were identified via the Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database 2007-2018. Thirty-day major complications were compared across BMI to identify an inflection point, to create a dichotomous BMI variable. Multivariable logistic regression was used to assess the association between BMI and complications. An interaction term was introduced to evaluate for effect modification by operative approach. RESULTS: A total of 26,940 patients were identified (25,933 BMI < 40, 1,007 BMI ≥ 40). The proportion of patients experiencing a major complication was higher in the BMI ≥ 40 group (2.0 vs 1.1%, P = 0.007). In multivariate analysis, the odds of a major complication was 1.8 times higher for women with a BMI ≥ 40 (95% confidence interval, 1.1-2.9, P = 0.04). There was a significant interaction between operative approach and BMI; therefore, further analyses were restricted to either vaginal or laparoscopic operative approaches. Among women who underwent vaginal prolapse repair, there was no difference in the odds of a major complication (adjusted odds ratio, 1.4; 0.8-2.4; P = 0.06). Among women who underwent laparoscopic repair, those with a BMI ≥ 40 were 6 times more likely to have a major complication (adjusted odds ratio, 6.0; 2.5-14.6; P < 0.001). CONCLUSIONS: Body mass index ≥ 40 was associated with an increased odds of a 30-day major complication. This association was greatest in women who underwent a laparoscopic prolapse repair.

Exosome biopotentiated hydrogel restores damaged skeletal muscle in a porcine model of stress urinary incontinence.

Urinary incontinence afflicts up to 40% of adult women in the United States. Stress urinary incontinence (SUI) accounts for approximately one-third of these cases, precipitating ~200,000 surgical procedures annually. Continence is maintained through the interplay of sub-urethral support and urethral sphincter coaptation, particularly during activities that increase intra-abdominal pressure. Currently, surgical correction of SUI focuses on the re-establishment of sub-urethral support. However, mesh-based repairs are associated with foreign body reactions and poor localized tissue healing, which leads to mesh exposure, prompting the pursuit of technologies that restore external urethral sphincter function and limit surgical risk. The present work utilizes a human platelet-derived CD41a and CD9 expressing extracellular vesicle product (PEP) enriched for NF-κB and PD-L1 and derived to ensure the preservation of lipid bilayer for enhanced stability and compatibility with hydrogel-based sustained delivery approaches. In vitro, the application of PEP to skeletal muscle satellite cells in vitro drove proliferation and differentiation in an NF-κB-dependent fashion, with full inhibition of impact on exposure to resveratrol. PEP biopotentiation of collagen-1 and fibrin glue hydrogel achieved sustained exosome release at 37 °C, creating an ultrastructural "bead on a string" pattern on scanning electron microscopy. Initial testing in a rodent model of latissimus dorsi injury documented activation of skeletal muscle proliferation of healing. In a porcine model of stress urinary incontinence, delivery of PEP-biopotentiated collagen-1 induced functional restoration of the external urethral sphincter. The histological evaluation found that sustained PEP release was associated with new skeletal muscle formation and polarization of local macrophages towards the regenerative M2 phenotype. The results provided herein serve as the first description of PEP-based biopotentiation of hydrogels implemented to restore skeletal muscle function and may serve as a promising approach for the nonsurgical management of SUI.

Three-Dimensional-Printed Vaginal Molds for Use After McIndoe Neovagina Creation.

BACKGROUND: Surgical vaginoplasty is a highly successful treatment for congenital absence of the vagina. One key to long-term success is the use of an appropriate vaginal mold in the immediate postoperative period. We present the use of a three-dimensional (3D)-printed vaginal mold, customizable to the anatomy of individual patients. TECHNIQUE: Vaginal molds were designed using a 3D modeling software program. The design included narrowing around the urethra, holes for egress of secretions, and a knob for insertion and removal. Dental resin was 3D-printed into various-sized vaginal molds, and postprocessing was performed. EXPERIENCE: We present the use of the 3D-printed mold for a patient with a history of cloacal exstrophy and a unique pelvic shape. Two prior neovagina surgeries in this patient had been unsuccessful due to ineffective handheld dilator use; the patient experienced success with the 3D-printed intravaginal mold. CONCLUSION: The use of the 3D-printed vaginal mold is an alternative to the limited commercially available models today and allows for customization to user anatomy. With 3D printers becoming more widely accessible, we believe this method could become universally accepted, with hopes of contributing to increased patient satisfaction and decreased complications.

Management of advanced prolapse including a bowel obstruction: expanding the role of transvaginal surgery.

INTRODUCTION AND HYPOTHESIS: We reviewed a case of concomitant advanced pelvic organ prolapse and partial small bowel obstruction managed via transvaginal small bowel resection and native tissue prolapse repair. METHODS: The patient is an 82-year-old woman with a history of a radical cystectomy and ileal conduit 2 years prior for bladder cancer that was transferred from an outside hospital for incarcerated prolapse including a small bowel obstruction with transition point inside the prolapse. She had previously unsuccessfully tried several pessaries for her prolapse. She was widowed and not sexually active. After conservative management of her bowel obstruction was unsuccessful, she was taken to the operating room for transvaginal prolapse repair. Intraoperatively, we encountered an isolated area of indurated bowel adherent to the prolapse. Colorectal surgery performed a transvaginal small bowel resection with stapled anastomosis, and a modified LeFort colpocleisis was performed to address her prolapse. Her postoperative course was uncomplicated, and at 6 months, she reported normal bowel function and had no evidence of prolapse recurrence. CONCLUSION: We present a case of incidental bowel pathology during vaginal prolapse surgery, requiring a small bowel resection. This case demonstrates the feasibility of this procedure when working with a multi-disciplinary team and localized bowel pathology.

Vesicouterine Fistula: A Robotic Approach.

INTRODUCTION AND HYPOTHESIS: This video demonstrates surgical repair of a vesicouterine fistula via a robotic, uterine-sparing approach. METHODS: In this video, we present a vesicouterine fistula, which occurred after cesarean delivery. The patient presented with cyclical hematuria 4 years following delivery. She underwent uterine-conserving robotic repair via excision of the fistula tract through an intentional cystotomy. The uterus and bladder were closed in multiple layers. RESULTS: The patient tolerated the procedure well, and CT cystogram 6 weeks following surgery demonstrated no concern for defect or recurrent fistulization. The patient was asymptomatic 9 months following her procedure. CONCLUSION: Repair of a vesicouterine fistula may be safely completed via a minimally invasive approach without need for routine hysterectomy.

Exosome-Induced Vaginal Tissue Regeneration in a Porcine Mesh Exposure Model.

OBJECTIVES: The purpose of this study was to explore the utility of an injectable purified exosome product derived from human apheresis blood to (1) augment surgical closure of vaginal mesh exposures, and (2) serve as a stand-alone therapy for vaginal mesh exposure. METHODS: Sixteen polypropylene meshes (1×1-3×3 cm) were implanted in the vaginas of 7 Yorkshire-crossed pigs by urogynecologic surgeons (day 0). On day 7, group 1 underwent surgical intervention via vaginal tissue suture reclosure with (n=2 pigs, n=4 meshes) or without (n=2 pigs, n=4 meshes) exosome injection; group 2 underwent medical intervention with an exosome injection (n=3, n=8 meshes). One animal in group 2 was given oral 2'-deoxy-5-ethynyluridine to track cellular regeneration. Euthansia occurred at 5 weeks. RESULTS: Mesh exposures treated with surgical closure alone experienced reexposure of the mesh. Exosome treatment with or without surgical closure resulted in partial to full mesh exposure resolution up to 3×3 cm. Exosome-treated tissues had significantly thicker regenerated epithelial tissue (208 µm exosomes-only and 217 µm surgery+exosomes, versus 80 µm for surgery-only; P < 0.05); evaluation of 2'-deoxy-5-ethynyluridine confirmed de novo regeneration throughout the epithelium and underlying tissues. Capillary density was significantly higher in the surgery+exosomes group (P = 0.03). Surgery-only tissues had a higher inflammatory and fibrosis response as compared with exosome-treated tissues. CONCLUSIONS: In this pilot study, exosome treatment augmented healing in the setting of vaginal mesh exposure, reducing the incidence of mesh reexposure after suture closure and decreasing the area of mesh exposure through de novo tissue regeneration after exosome injection only. Further study of varied local tissue conditions and mesh configurations is warranted.

Teaching the art of LeFort colpocleisis: a moderate-fidelity, low-cost simulation model.

The objective was to demonstrate the build and use of a low-cost, moderate-fidelity simulation model for LeFort colpocleisis. We a present a video demonstrating the creation of a LeFort colpocleisis model, the mounting of this model to a pre-existing vaginal hysterectomy simulator (SimVaHT), and the use of the model to teach the steps of the LeFort colpocleisis procedure. This LeFort colpocleisis model is easy to make, from readily available materials, and is inexpensive. It can help trainees to enhance their intraoperative learning.

Impact of Repeat Dosing and Mesh Exposure Chronicity on Exosome-Induced Vaginal Tissue Regeneration in a Porcine Mesh Exposure Model.

OBJECTIVE: The aim of the study was to compare vaginal wound healing after exosome injection in a porcine mesh exposure model with (1) single versus multiple dose regimens and (2) acute versus subacute exposure. METHODS: Six 80-kg Yorkshire-crossed swine each had 2 polypropylene meshes implanted to create the vaginal mesh exposure model. Animals were divided into 3 groups based on number and timing of exosome injection: (1) single purified exosome product (PEP) injection (acute-single), (2) weekly PEP injections (acute-weekly, 4 total injections), and (3) delayed single injection (subacute-single). Acute and subacute injections occurred 1 and 8 weeks after mesh implantation, respectively. EdU, a thymidine analog, was given twice weekly after the first injection to track tissue regeneration. Euthanasia and tissue analysis occurred 4 weeks after the first injection. ImageJ was used to quantify epithelial thickness, cellular proliferation, and capillary density. Statistical analysis was performed using analysis of variance and post hoc Tukey test. RESULTS: Acute-single PEP injection tissues mirrored pilot study results, validating replication of protocol. Within the acute groups, weekly dosing resulted in 1.5× higher epithelial thickness (nonsignificant), 1.8× higher epithelial proliferation (P < 0.05), and 1.5× higher regenerated capillary density (P < 0.05) compared with single injection. Regarding chronicity of the exposure, the subacute group showed 1.7× higher epithelial proliferation (nonsignificant) and similar capillary density and epithelial thickness as compared with the acute group. CONCLUSIONS: Exosome redosing resulted in significantly greater epithelial proliferation with significantly higher regenerated capillary density, leading to a trend toward thicker epithelium. Subacute exposure exhibited similar regeneration to acute exposure despite a delayed injection timeline. These results contribute to a growing body of preclinical research demonstrating utility of exosomes in pelvic floor disorders.

Surgical management of stress urinary incontinence following traumatic pelvic injury.

INTRODUCTION AND HYPOTHESIS: The objective was to discuss the evaluation and management of stress urinary incontinence (SUI) following traumatic pelvic injury by use of a video case. METHODS: We present a patient with severe SUI following pelvic trauma and our surgical approach to her case. Her injuries included two sacral compression fractures and four un-united bilateral pubic rami fractures, with her right-upper pubic rami impinging on the bladder. RESULTS: Preoperative assessment included detailed review of her pelvic imaging, multichannel urodynamic testing, cystoscopy, and examination of periurethral and bony pelvis anatomy. We proceeded with a synthetic retropubic mid-urethral sling, which required medial deviation of the trocar passage owing to her distorted anatomy. Rigid cystoscopy provided an inadequate bladder survey following sling placement, thus flexible cystoscopy was used to confirm the absence of bladder perforation. Postoperatively, our patient experienced resolution of SUI. CONCLUSIONS: In patients who sustain pelvic fractures, imaging to evaluate bony trauma and genitourinary tract injury is essential. Urodynamic testing provides clarity of the nature and severity of incontinence symptoms. Rigid and/or flexible cystoscopy should be performed for diagnostic purposes pre-operatively and after operative intervention. Typical anti-incontinence procedures can be offered to these patients, but since bony anatomy can be unreliable, an individualized approach to their specific injury should be utilized.

Perioperative Complications in Minimally Invasive Sacrocolpopexy Versus Transvaginal Mesh in the Management of Pelvic Organ Prolapse: Analysis of a National Multi-institutional Dataset.

OBJECTIVES: The objective of this study was to evaluate perioperative complications in women who underwent minimally invasive sacrocolpopexy (MISC) versus mesh-augmented vaginal repair (vaginal mesh) for pelvic organ prolapse. METHODS: We identified patients undergoing MISC and vaginal mesh via Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2016. Those undergoing concomitant hysterectomy were excluded. Univariate analyses were performed to compare baseline characteristics and 30-day complications. Multivariable logistic regression models were constructed to assess the association between surgical approach and complications, prolonged hospitalization, reoperation, and blood transfusion. A multivariable Cox proportional hazard model was used to evaluate hospital readmission. RESULTS: A total of 5722 patients were identified (2573 MISC [45%], 3149 vaginal mesh [55%]). Those undergoing MISC repairs had a significantly lower rate of urinary tract infection (3.1 vs 4.2%; P = 0.03) and blood transfusion (0.5 vs 1.4%; P < 0.001). There was no difference in reoperation rate (1.3 vs 1.6%; P = 0.35). Multivariable analysis showed no significant association of MISC with overall (odds ratio [OR], 0.91; P = 0.44), major (OR, 1.30; P = 0.31), or minor complication (OR, 0.85; P = 0.26). There were lower odds of receiving a blood transfusion (OR, 0.44; P = 0.02) and higher odds of prolonged hospitalization (>2 days; OR, 1.47; P = 0.003) for the MISC group. There was no difference in reoperation (OR, 0.79; P = 0.38) or hospital readmissions (hazard ratio, 1.25, P = 0.32). CONCLUSIONS: Minimally invasive sacrocolpopexy was associated with a lower rate of blood transfusion than transvaginal mesh placement. There was no significant difference in 30-day complication rates, reoperation, or readmission between these prolapse procedures when performed without concomitant hysterectomy.

Management of Vaginal Mesh Exposures Following Female Pelvic Reconstructive Surgery.

PURPOSE OF REVIEW: To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery. RECENT FINDINGS: Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on the patient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.

Ultrasound vibro-elastography for assessing mechanical properties of porcine reproductive tissues in an ex vivo model.

BACKGROUND: The aim of this study was to use ultrasound vibro-elastography (UVE) for measuring surface wave speed and assessing mechanical properties of ex vivo porcine reproductive tissues, including the uterus, bladder, cornua and cervix. METHODS: In UVE, a 0.1-s harmonic vibration at low frequency was generated on the tissue surface with a handheld shaker. A linear-array ultrasound probe was used to measure the resulting surface wave propagation. Surface wave speeds of tissues were measured in the frequency range of 100-300 Hz. Mechanical properties of the tissue were calculated based on wave speed dispersion with frequency. FINDINGS: The obtained results showed that the surface wave speeds of porcine bladder, cervix, cornua and uterus increased with frequency. There were no statistically significant differences in the wave speeds or mechanical properties among the porcine bladder, cervix, cornua and uterus. INTERPRETATION: Experimental data obtained in this study may be used as a reference to study in vivo surface wave speed or mechanical properties for porcine or human reproductive tissues.

Teaching learners to raise the roof: a vaginal surgery simulator for apical suspension.

INTRODUCTION AND HYPOTHESIS: The objective was to discuss the importance of apical suspension following vaginal hysterectomy and demonstrate a surgical model to aide in educating learners on a variety of apical suspension procedures. METHODS: Rates of pelvic organ prolapse are not insignificant following hysterectomy. Re-support of the vaginal apex should be performed at the time of hysterectomy in those with or without a diagnosis of prolapse. Exposure to vaginal apical support procedures may be limited owing to declining rates of vaginal hysterectomy and limited trainee work hours. Surgical models are increasingly being used to supplement operating room experience. The model we present was originally developed for hysterectomy, although its design allows for teaching a variety of apical support procedures that incorporate the uterosacral ligament (USL) for support. We demonstrate performing a USL suspension, internal McCall suture, and modified McCall suture using the model. RESULTS: The model is constructed from readily available supplies, is multi-use, and inexpensive. It allows learners to identify relevant anatomy, understand/visualize surgical steps, and practice suturing technique. CONCLUSION: Pelvic organ prolapse is common in women, although opportunities to teach apical suspension procedures may be limited. The proposed vaginal surgery simulator can be used to supplement the experience of gynecological surgery trainees with apical suspension procedures.

Randomized Controlled Trial to Assess the Impact of Intraurethral Lidocaine on Urodynamic Voiding Parameters.

OBJECTIVES: The aim of the study was to determine whether intraurethral anesthesia decreases voiding efficiency (VE; voided volume/(voided volume + residual volume)) and impacts other urodynamic parameters in healthy female volunteers during urodynamic studies. METHODS: This was a randomized double-blind placebo-controlled study of asymptomatic women aged 18 to 60 years. Subjects completed a visual analog scale and baseline questionnaires to assess pain and lower urinary tract symptoms, respectively. They performed an uninstrumented baseline uroflow, followed by physiologic filling to 250 mL or greater. Subjects were randomized to receive 5 mL of intraurethral aqueous gel or 2% lidocaine gel and then underwent a second uninstrumented uroflow. They then completed complex cystometry, urethral pressure profilometry, and pressure-flow studies. RESULTS: Twenty-three randomized subjects (12 placebo, 11 lidocaine) were included. Baseline uroflow VE was similar between the placebo and lidocaine groups. After study drug administration, VE was not different between groups (89.3 [85.9-93.9] vs 89.5 [82.5-91.7], P = 0.74). There were also no differences between groups in visual analog scale scores, sensation during cystometry, maximum urethral closure pressure, or micturition parameters (maximum detrusor pressure and detrusor pressure at maximum flow). The placebo group had a lower percentage of interrupted flow pattern (0% vs 36%, P = 0.02) and a lower rate of increased electromyographic activity during micturition (25% vs 73%, P = 0.02). CONCLUSIONS: In this pilot study of 23 asymptomatic women, intraurethral administration of lidocaine did not decrease VE compared with placebo. The lidocaine group had a greater percentage of interrupted flow patterns and increased electromyographic activity during micturition.

Same-Day Discharge After Robotic-Assisted Sacrocolpopexy.

OBJECTIVE: The aim of the study was to compare unplanned postoperative encounters in women discharged same day versus later after robotic-assisted sacrocolpopexy (RA-SCP). METHODS: This is a retrospective cohort study of women who underwent RA-SCP at a tertiary care center January 2013 to September 2015. Women were divided into 2 cohorts based on their day of discharge: (1) same day or (2) postoperative day 1 (POD ≥ 1) or later. Our primary outcome was unplanned provider visits (clinic, urgent care, emergency department, or hospital readmission) during the 6 weeks after surgery. Secondary outcomes included unplanned postdischarge nurse or physician phone calls. Logistic regression models were created to control for potential confounders. RESULTS: Two hundred seventy-two women were included; 80 underwent same-day discharge versus 192 discharged POD 1 or later (187 on POD 1, 5 on POD 2). Women discharged same day were older (61.3 vs 58.5 years, P < 0.05), more likely to have a start time before noon (85% vs 67.6%, P < 0.01), received less intraoperative intravenous fluids (1153 mL vs 1536 mL, P < 0.01), had shorter procedures (237 vs 256 minutes, P < 0.01), and spent more time in the postanesthesia care unit (213 vs 158 minutes, P < 0.01). There were no differences in unplanned provider visits between women discharged same day versus later (18.8% vs 27.6%, P = 0.12). No differences were observed in unplanned clinic visits, emergency department visits, or readmissions. In logistic regression models, unplanned provider visits (odds ratio = 0.35, 95% confidence interval = 0.30-1.54) and phone calls (odds ratio = 0.69, 95% confidence interval = 0.54-2.58) were not significantly different between groups. CONCLUSIONS: Same-day discharge after RA-SCP is safe and does not result in increased health care utilization (provider visits or postoperative phone calls).

Effect of virtual reality on time perception in patients receiving chemotherapy.

PURPOSE: Virtual reality (VR) during chemotherapy has resulted in an elapsed time compression effect, validating the attention diversion capabilities of VR. Using the framework of the pacemaker-accumulator cognitive model of time perception, this study explored the influence of age, gender, state anxiety, fatigue, and cancer diagnosis in predicting the difference between actual time elapsed during receipt of intravenous chemotherapy while immersed in a VR environment versus patient's retrospective estimates of time elapsed during this treatment. MATERIALS AND METHODS: This secondary analysis from three studies yielded a pooled sample of N = 137 participants with breast, lung, or colon cancer. Each study employed a crossover design requiring two matched intravenous chemotherapy treatments, with participants randomly assigned to receive VR during one treatment. Regressions modeled the effect of demographic variables, diagnosis, and Piper Fatigue Scale and State Anxiety Inventory scores on the difference between actual and estimated time elapsed during chemotherapy with VR. RESULTS: In a forward regression model, three predictors (diagnosis, gender, and anxiety) explained a significant portion of the variability for altered time perception (F=5.06, p = 0.0008). Diagnosis was the strongest predictor; individuals with breast and colon cancer perceived time passed more quickly. CONCLUSIONS: VR is a noninvasive intervention that can make chemotherapy treatments more tolerable. Women with breast cancer are more likely and lung cancer patients less likely to experience altered time perception during VR (a possible indicator of effectiveness for this distraction intervention). Understanding factors that predict responses to interventions can help clinicians tailor coping strategies to meet each patient's needs.