Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies.

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.

Guidelines for the selection of the route of hysterectomy: application in a resident clinic population.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the Society of Pelvic Reconstructive Surgeons guidelines for the determination of the route of hysterectomy in a resident clinic population. STUDY DESIGN: A total of 407 consecutive women from the resident clinic population at Wright State University between October 1, 1994, and December 31, 1999, were assigned prospectively to abdominal or vaginal hysterectomy groups according to Society of Pelvic Reconstructive Surgeons guidelines. The women's age, race, and preoperative and postoperative uterine weights, length of stay, laparoscopic scores, operative time, and complications were compared. RESULTS: Vaginal hysterectomy was completed successfully in 91.8% of the women. As expected, vaginal hysterectomy required the shortest operative time and length of stay and was associated with fewer complications than the abdominal approach (P <.01). Laparoscopic assistance was necessary in 25.8% of patients to assess extrauterine disease. CONCLUSION: Resident physicians who followed the practice guidelines reduced the ratio of abdominal-to-vaginal hysterectomy from 3:1 to 1:11. The application of practice guidelines for the selection of the route of hysterectomy can increase the ratio of vaginal hysterectomies that are performed in residency programs and can help eradicate inconsistencies in health care delivery that exist currently.