Surgical Outcomes of Paravaginal Repair After Robotic Sacrocolpopexy.

STUDY OBJECTIVE: To evaluate surgical outcomes of robotic sacrocolpopexy with and without paravaginal repair for pelvic organ prolapse (POP). DESIGN: A retrospective cohort study with a 3-month postoperative follow-up (Canadian Task Force classification II-3). SETTING: An academic-affiliated community hospital with a practice comprised of 3 surgeons board certified in female pelvic medicine and reconstructive surgery. PATIENTS: Patients undergoing robotic sacrocolpopexy for POP from April 2013 through November 2014. INTERVENTIONS: Robotic paravaginal repair (RPVR) after robotic sacrocolpopexy. The decision to perform a paravaginal repair was at the discretion of the surgeon. MEASUREMENTS AND MAIN RESULTS: One hundred fifty-six patients underwent a robotic sacrocolpopexy. Twenty-four patients were excluded because of a lack of a 3-month postoperative follow-up. Nine patients underwent concomitant vaginal paravaginal repair and were also excluded. Outcomes were defined by comparing preoperative characteristics with those at the 3-month follow-up. Of the 123 patients in this cohort, 21 patients underwent a concomitant RPVR, and 102 did not. All Pelvic Organ Prolapse Questionnaire (POP-Q) points improved within groups (p < .001) except for the total vaginal length (TVL) in the RPVR group (p = .940). The Patient Global Impression of Improvement (PGI-I) did not differ between groups (1.2 vs 1.5, p = .128). Subgroup analysis was performed on patients with preoperative anterior wall prolapse of stage 3 or greater. Baseline characteristics and perioperative data were not remarkably different from the main cohort. All POP-Q points improved within groups (p < .001) except for the TVL in the RPVR group (p = .572). The PGI-I did not differ between groups (1.2 vs 1.3, p = .378). CONCLUSION: In both groups, anatomic markers substantially improved within each group. There were significant differences in postoperative POP-Q findings, which may have been influenced by the fact that patients undergoing RPVR usually had worse baseline prolapse. This selection bias creates difficulty with interpretation. Although in this study RPVR did not change subjective outcomes, further study is necessary to control for the severity of prolapse.

Cetacean sightings and acoustic detections during a seismic survey off Nicaragua and Costa Rica, November-December 2004 / Avistamientos y detecciones acústicas de cetáceos durante un sondeo sísmico en aguas fuera de las costas de Nicaragua y Costa Rica, en Noviembre y Diciem bre 2004

AbstractAlthough the wider Eastern Tropical Pacific has been systematically surveyed during summer/fall, relatively little effort has focused on shelf and slope waters of Nicaragua and Costa Rica. Such data are useful for establishing baseline information and assessing potential changes in cetacean occurrence and distribution relative to natural (e.g., El Niño-Southern Oscillation, climate change) and anthropogenic factors. A visualacoustic survey for cetaceans occurred as part of a monitoring and mitigation program during an academic geophysical seismic study off Nicaragua and Costa Rica, during November-December 2004. Approximately 2 067 cetaceans representing at least seven species were seen in 75 groups during 373 h (3 416 km) of daytime observations from the seismic research vessel (R/V) Maurice Ewing. The humpback whale (Megaptera novaeangliae) and the pantropical spotted dolphin (Stenella attenuata) were the most frequently sighted species (30 % of all groups sighted); both were seen in shelf waters < 100 m deep and in slope waters. The bottlenose dolphin (Tursiops truncatus; 10 % of sightings) was the third most frequently sighted species and was only seen in water > 100 m deep. In addition, sightings were made of spinner dolphins (S. longirostris), short-beaked common dolphins (Delphinus delphis), Risso's dolphins (Grampus griseus), short-finned pilot whales (Globicephala macrorhynchus), and unidentified dolphins and whales. Unconfirmed sightings of a minke whale (Balaenoptera acutorostrata) and a pod of false killer whales (Pseudorca crassidens) were also recorded. An additional six groups of dolphins (50 % confirmed to species, all pantropical spotted dolphins) were made during 187 h (1 549 km) of observation effort during darkness, two of which were detected within 30 m of the vessel bow using a night vision device. A total of 217 cetacean detections occurred during 633 h of passive acoustic monitoring. A small concentration of 12 humpback whales was seen in eight groups, and two humpbacks were recorded singing in the Gulf of Fonseca on 9 December 2004. To our knowledge, such concentrations of humpback whales, particularly singing humpbacks, have not been previously reported in this specific area. In addition, a humpback mother-calf pair, likely from the Northern Hemisphere population, was seen off Northern Costa Rica on 25 November 2004. Although cetacean sighting rates were significantly different during seismic and non-seismic periods even when corrected for differential detection probability related to sea conditions, our survey results do provide information to address previous data gaps on cetacean occurrence in shelf and slope waters off the Pacific coast of Central America during late fall.

ResumenAunque el ancho Pacífico Tropical Oriental ha sido sistemáticamente sondeado durante el verano/otoño, relativamente poco esfuerzo se ha aplicado tanto en aguas de la plataforma continental como el talud de Nicaragua y Costa Rica. Tales datos son útiles para establecer una información base y evaluar los cambios potenciales en la presencia y distribución relacionada tanto a factores naturales (ej., fenómeno de El Niño, cambio climático) como a factores antropogénicos. Un sondeo visual y acústico de cetáceos fue realizado como parte de un programa de monitoreo y mitigación durante un estudio académico de geofísica (sísmica) en las afueras de las costas de Nicaragua y Costa Rica durante Noviembre y Diciembre 2004. Aproximadamente 2 067 cetáceos representantes de al menos siete especies fueron avistados en 75 grupos durante 373 h (3 416 km) de observación diurna desde el buque de prospección sísmica (R/V) Maurice Ewing. La ballena jorobada (Megaptera novaeangliae) y el delfín manchado pantropical (Stenella attenuata) fueron las especies más frecuentemente avistadas (30 % de todos los grupos avistados); ambas fueron avistadas tanto en aguas de la plataforma continental < 100 m de profundidad como en aguas del talud. El delfín nariz de botella (Tursiops truncatus; con un 10 % de los avistamientos) fue la tercera especie más avistada, solamente visto en aguas > 100 m de profundidad. Adicionalmente, se registraron avistamientos de delfines acróbatas (S. longirostris), delfines comunes de hocico corto (Delphinus delphis), calderones grises (Grampus griseus), ballenas piloto de aleta corta (Globicephala macrorhynchus) además de ballenas y delfines no identificados. También se registró un avistamiento no confirmado de una ballena de minke (Balaenoptera acutorostrata) y uno de un grupo de falsas orcas (Pseudorca crassidens). Un adicional de seis avistamientos de delfines (confirmándose en un 50 % de ellos para la especie de delfín manchado pantropical) se observaron durante 187 h (1 549 km) de esfuerzo durante lapsos de oscuridad, dos de los cuales se detectaron a 30 m de la proa de la embarcación utilizando dispositivos de visión nocturna. Un total de 217 detecciones de cetáceos ocurrieron durante 633 h de monitoreo acústico pasivo. Una pequeña concentración de 12 ballenas jorobadas fue avistada en ocho grupos, y dos jorobadas fueron registradas cantando en el Golfo de Fonseca el 9 de Diciembre 2004. Para nuestro conocimiento, tal concentración de ballenas jorobadas, particularmente jorobadas cantando, no han sido reportadas previamente en esta área específica. Adicionalmente, una pareja de jorobadas madre-cría, probablemente de la población del Hemisferio Norte, fue avistada en las afueras de la costa de Costa Rica el 25 de Noviembre 2004. A pesar de que las tasas de avistamiento fueron significativamente distintas durante los periodos sísmicos y no sísmicos, incluso siendo corregidos según la probabilidad de detecciones relacionadas a las condiciones del mar, nuestro sondeo provee información que cubre vacíos previos de datos en la presencia de cetáceos en las aguas tanto de la plataforma como del talud continental fuera de las costas del Pacífico de América Central durante el otoño tardío.

Hydrodistention of the bladder for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC).

AIMS: The purpose of this study is to determine whether a transvaginal trigonal block immediately preceding cystoscopy with hydrodistention yields an additional therapeutic benefit compared to cystoscopy with hydrodistention alone for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS: A retrospective chart review was performed at a single-center. Performance of a trigonal block prior to hydrodistention was at the discretion of the surgeon. A trigonal block consists of injecting 0.25% bupivacaine with 1.0% Xylocaine into the anterior vagina under the trigone under cystoscopic guidance. Procedures between January 1, 2008 and December 31, 2013 were included. The primary outcome compared change in pain score from the baseline to 1-month post-operative. RESULTS: One hundred and eighty-three patients underwent hydrodistention of the bladder. Seventy-seven were excluded and of the 106 patients remaining, 48 received a trigonal block and 58 did not. Both groups had a significant improvement in pain scores (P < 0.0001). There was no difference in change in pain score from baseline between both groups (-2.9 vs. -2.6; P = 0.694). Distention time was dichotomized into 2 and >5 min based on surgeon preference. There was no difference in change in pain score from baseline between both groups (-3.0 vs. -2.2; P = 0.061). CONCLUSIONS: Hydrodistention of the bladder decreased pain postoperatively regardless of trigonal block or time of distention. A randomized-controlled trial is necessary to determine the benefits of duration of hydrodistention or performance of a block. Neurourol. Urodynam. 36:784-786, 2017. © 2016 Wiley Periodicals, Inc.

Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison.

UNLABELLED: Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison. PURPOSE: To determine if local injection, prior to incision with lidocaine plus epinephrine (L + E) influences the rate of mesh exposure in the early postoperative period following synthetic mesh augmented vaginal reconstructive surgery (MAVR). METHODS: We performed a chart review over an 18-month period of patients who underwent MAVR. The presence of mesh exposure at the 3-month postoperative visit, demographic data and whether or not L + E was used to hydrodissect was recorded. Statistical analysis was performed to determine whether hydrodissection influenced erosion rates. RESULTS: A total of 143 meshes were placed, hydrodissection with L + E was used in 78 cases and was not in the remaining 65 cases. There were 10 (7.0% 10/143) total erosions at the 3-month postoperative visit, 6 (7.7%; 6/78) in the group that got L + E and 4 (6.2%; 4/65) in the group that did not get local injection. This difference was not significant (p = 0.740, OR 1.54 95% CI 0.41-5.76). There was no difference between the two groups in terms of age, presence of diabetes, concurrent incontinence repair or estimated blood loss. CONCLUSION: Mesh exposure is a known complication of MAVR. Our study suggests that local injection with L + E prior to vaginal surgery does not influence exposure rates.

A multicenter prospective trial evaluating fetal bovine dermal graft (Xenform® Matrix) for pelvic reconstructive surgery.

BACKGROUND: A prospective multicenter clinical study was performed to evaluate the safety and efficacy of a bovine dermal graft (Xenform® Matrix, Boston Scientific, Natick, MA, USA) during vaginal reconstructive surgery. METHODS: Forty-five women with ICS stage 2 or higher pelvic organ prolapse (POP) were enrolled at 4 centers. POP-Q, pelvic floor function (PFDI-20), sexual function (PISQ-12), and patient satisfaction tools were used to assess subjects at baseline, and at 2 and 6 weeks, and 3, 6 and 12 months post surgery. The significance of symptom score changes at 6 months and 1 year were determined by the t-test for paired data. Forty-three of the 45 patients completed the 12 month study. RESULTS: The majority of the subjects had cystocele (98%) and/or rectocele (84%) defects at study entry. At 12 months, 74% of the defects had improved to a stage 0 or 1. Mean PFDI-20 scores improved by 72% (p < 0.001) at 12 months, and PISQ-12 scores were maintained during the follow-up period indicating no decline in sexual function. Three subjects experienced one serious adverse event each; one of the adverse events (constipation) was deemed by the study physician to be unrelated to Xenform®. One subject had severe pyelonephritis resulting in dialysis. This subject had a previous history of pyelonephritis, sepsis and acute renal failure. The third subject had a reported recurrent cystocele of moderate severity, possibly related to the device. No graft related erosions or pain lasting more than 30 days were reported. No subjects withdrew due to an adverse event. CONCLUSION: This study is the first to investigate the use of Xenform® Matrix in vaginal reconstructive surgery among patients with POP. Significant improvement was maintained at 12 months utilizing both objective and subjective assessment tools, confirming the safety and efficacy of this material in vaginal surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01244165.

Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs.

INTRODUCTION AND HYPOTHESIS: Our objective was to establish the overall graft erosion rate in a synthetic graft-augmented repair 3 months postoperatively. METHODS: A retrospective chart review was performed on a cohort of subjects who underwent mesh-augmented vaginal reconstructive surgery during an 18-month period. We defined graft erosion as exposure of any mesh upon visual inspection of the entire vagina at the 3-month postoperative visit. Statistical tests performed to evaluate proportional differences were the Pearson chi square and Fisher exact tests. Independent t test was performed to compare mean differences. RESULTS: A total of 124 grafts were implanted. The overall erosion rate was 11.3%. There was a significantly lower erosion rate when using "commercial kits" vs. our traditional repairs (1.4% [one out of 69] vs. 23.6% [13 out of 55]; p < 0.001). CONCLUSIONS: Our study demonstrates a significantly lower erosion rate when using a "commercial kit" to repair pelvic organ prolapse compared to our traditional synthetic graft-augmented repair.

Characteristics of physicians who choose fellowship training in obstetrics and gynecology.

INTRODUCTION: : To determine the attributes and motivation of physicians who pursue fellowship training in the subspecialties of Obstetrics and Gynecology (Ob/Gyn). METHODS: : We surveyed current fellows and recent graduates from the ABOG recognized subspecialties in Ob/Gyn. Demographics and reasons for pursuing fellowship training were obtained. Significant differences between and among groups were determined using the Mann-Whitney U test and Pearson χ test. RESULTS: : Forty-two percent of those sent a survey responded. The majority were between ages 30 to 35 (65.7%), female (60.5%), married (74.5%), and White (68.8%). Over 55% in each subspecialty cited interest in subject area as the primary reason for choosing their fellowship. CONCLUSION: : Interest in subject remains the primary motivation for the majority of physicians choosing subspecialty fellowship training in Ob/Gyn. There is considerably more variation regarding what physicians' secondary motivation is and these reasons appear to vary according to the particular subspecialty.

The effect of zoledronic acid on bone mineral density in patients undergoing androgen deprivation therapy.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of zoledronic acid compared with placebo in preventing bone mineral density (BMD) loss and suppressing bone markers when initiated during the first year of androgen deprivation therapy in patients with locally advanced prostate cancer. PATIENTS AND METHODS: Patients were randomized to receive zoledronic acid 4 mg or placebo intravenously every 3 months. Lumbar spine (LS) and total hip BMD was measured using dual-energy x-ray absorptiometry at baseline and at week 52. N-telopeptide (NTX) and bone-specific alkaline phosphatase (BSAP) were evaluated at baseline and every 12 weeks. Safety assessments were performed throughout the study. RESULTS: Efficacy analyses included 106 patients and 109 patients in the zoledronic acid and placebo groups, respectively. At week 52, the least squares mean BMD percentage differences were 6.7% for LS and 3.7% for total hip (P < 0.0001 for both). In the zoledronic acid group, decreases in NTX ((-)14% to (-)28%) and BSAP ((-)31% to (-)37%) levels were significant and sustained; changes in NTX levels and LS BMD (r = (-)0.25; P = 0.04) and in BSAP levels and hip BMD (r = (-)0.28; P = 0.02) were significantly correlated. Only traumatic fractures were reported for 2 and 3 patients receiving zoledronic acid and placebo, respectively. One patient in each group experienced acute renal failure. Osteonecrosis of the jaw was not reported. CONCLUSION: Zoledronic acid (4 mg intravenously every 3 months) was safe and effective in preventing bone loss and reducing bone turnover in patients with prostate cancer when initiated during the first year of androgen deprivation therapy; patients with low baseline BMD experienced the greatest benefit.

A menopausal woman with mullerian agenesis, a leiomyoma, an inguinal hernia, and cystadenofibromas.

BACKGROUND: Müllerian agenesis, the second most common cause of primary amenorrhea, affects 1 in 4,000 to 10,000 women. Although the majority of these women have complete absence of the uterus, a small percentage can have a rudimentary uterus. CASE: A menopausal nulligravida with known müllerian agenesis developed a large pelvic mass and an inguinal hernia. The patient underwent an exploratory laparotomy, which revealed a large leiomyoma growing from a small rudimentary uterus, an indirect inguinal hernia, and bilateral benign serous cystadenofibroma. CONCLUSION: Women with müllerian agenesis and rudimentary uteri can develop gynecologic pathology similar to women with normal genital tracts.