Contained specimen morcellation during robotics-assisted laparoscopic supracervical hysterectomy for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology. METHODS: A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL). RESULTS: Median CMM time was 11 min (1 to 46) and specimen weight 62 g (19 to 711). Median patient age was 56 years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50 ml (10 to 150). Median skin and fascial incision lengths were 3 cm (1.5 to 7), and 3.5 cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5 years after surgery patients were cancer free. CONCLUSION: Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal.

Multidisciplinary Management of Cutaneous Gluteus Vaginal Fistula After Sacrospinous Ligament Fixation.

Introduction: Cutaneous gluteal vaginal fistula is a rare but significant postoperative complication which may present years after sacrospinous ligament fixation (SSLF) surgery There is limited data on the management of cutaneous vaginal fistula following SSLF. Case description: This case report describes a 77-year-old who presents twenty years after SSLF with cutaneous gluteal vaginal abscess and fistula. She underwent successful management with CT-guided percutaneous drainage of gluteal abscess and placement of guiding cutaneous vaginal catheter, laparoscopic pelvic wall dissection and evaluation, and transvaginal localization and removal of the infected permanent suture. Discussion: Multi-disciplinary approach should be considered in the treatment of chronic fistula status post SSLF, including interventional radiology, urogynecology, and minimally invasive gynecologic surgery.

Improved Understanding of Female Pelvic Medicine and Reconstructive Surgery Concepts Through Targeted Case-Based Educational Intervention: A Pilot Study.

OBJECTIVES: Given the complex anatomy and pathophysiology of urogynecologic disorders, obstetrics and gynecology residents can have difficulty learning the subject's principles. There are no standardized resources for educators in this subspecialty. We hypothesized that our case-based educational intervention was associated with enhanced knowledge and greater resident satisfaction versus traditional urogynecology lectures. METHODS: This is a prospective study involving 19 obstetrics and gynecology residents at a single institution. Residents participated in three 1-hour case-based lectures, which included prelecture and postlecture topic knowledge assessments. Nonparametric Wilcoxon signed-rank tests were used to compare the before and after responses. Resident satisfaction was assessed using a 5-point Likert scale questionnaire. RESULTS: The median scores for the pretraining and posttraining assessments of resident urogynecology subject knowledge were 8 (5-10) and 10 (8-10), respectively. A stratified analysis was performed based on postgraduate year (PGY) and median prelectures and postlectures scores showed statistically significance (P < 0.001). Analysis of the PGY subgroups demonstrated statistical significance in PGY1 (P = 0.004), PGY2 (P = 0.008), and PGY3 (P = 0.03). However, the PGY4 subgroup (P = 0.06) did not reach statistical significance.All residents regardless of PGY level either agreed or strongly agreed that the case-based educational intervention enhanced resident knowledge, engagement, and clarity of the relevant teaching points and decreased resident stress about urogynecology topics. CONCLUSIONS: The case-based educational intervention significantly improved resident knowledge in urogynecology and enhanced resident satisfaction with this teaching method versus traditional lectures.

Outcomes of stress urinary incontinence in women undergoing TOT versus Burch colposuspension with abdominal sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: To compare postoperative rates of stress urinary incontinence (SUI) in patients with pelvic organ prolapse and SUI undergoing abdominal sacrocolpopexy (ASC) with Burch colposuspension or a transobturator tape (TOT) sling. METHODS: In this retrospective cohort study, medical records of 117 patients who underwent ASC with Burch (n = 60) or TOT (n = 57) between 2008 and 2010 at NYU Winthrop Hospital were assessed. Preoperative evaluation included history, physical examination, cough stress test (CST), and multichannel urodynamic studies (MUDS). Primary outcomes were postoperative continence at follow-up up to 12 weeks. Patients considered incontinent reported symptoms of SUI and had a positive CST or MUDS. Secondary outcomes included intra- and postoperative complications. Associations were analyzed by Fisher's exact, McNemar's and Wilcoxon-Mann-Whitney tests. RESULTS: The groups were similar regarding age, BMI, parity, Valsalva leak point pressure (VLPP), and prior abdominal surgery (p = 0.07-0.76). They differed regarding preoperative SUI diagnosed by self-reported symptoms, CST, or MUDS (TOT 89.5-94.7%, Burch 60.7-76.3%, p < 0.0001-0.007). The TOT group had lower rates of postoperative SUI (TOT 12.5%, Burch 30%, OR = 0.15, 95% CI 0.04, 0.62). Relative risk reduction (RRR) in postoperative SUI for the TOT group compared with the Burch group was 79%-86%. There were no differences concerning intra- and postoperative complications. The Burch group had a higher rate of reoperation for persistent/recurrent SUI (Burch 25%, TOT 12% p = 0.078). CONCLUSIONS: The TOT group experienced a greater reduction in postoperative incontinence, and the Burch group underwent more repeat surgeries. The TOT sling may be superior in patients undergoing concomitant ASC.

Impact of Obesity on Robotic-Assisted Sacrocolpopexy.

STUDY OBJECTIVE: To compare operative time in women stratified by body mass index (BMI) undergoing robotic-assisted sacrocolpopexy (RASC). Secondary objectives included characterizing perioperative characteristics and reoperation rates. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: One hundred seventy-nine consecutive patients who underwent RASC by a single surgeon from 2009 through 2013. INTERVENTIONS: RASC. MEASUREMENTS AND MAIN RESULTS: Of 179 patients, 61 (34%) were normal weight (BMI < 25 kg/m2), 72 (40%) were overweight (BMI 25-30 kg/m2), and 46 (26%) were obese (BMI ≥ 30 kg/m2). Overweight patients were significantly older, more parous, more frequently postmenopausal, and more frequently underwent concomitant salpingo-oophorectomy. Median operative times were 202, 206, and 216 minutes in the normal-weight, overweight, and obese groups, respectively (p = .53). CONCLUSION: Obese women undergoing RASC have similar operative time and procedural characteristics as normal-weight and overweight patients. Longer term outcomes are needed to ensure comparable surgical and anatomic success.

Update on Urinary Tract Markers in Interstitial Cystitis/Bladder Pain Syndrome.

Interstitial cystitis (IC)/painful bladder syndrome/bladder pain syndrome (BPS) is a chronic hypersensory condition of unknown etiology. Moreover, the optimal modality for diagnosing IC remains disputed. Several urinary markers have been investigated that may have potential utility in the diagnosis or confirmation of IC/BPS. Thus, inflammatory mediators, proteoglycans, urinary hexosamines, proliferative factors, nitric oxide (NO), BK polyomavirus family, and urothelial proinflammatory gene analysis have been found to correlate with varying degrees with the clinical diagnosis or cystoscopic findings in patients with IC/BPS. The most promising urinary biomarker for IC/BPS is antiproliferative factor, a sialoglycopeptide that has demonstrated inhibitory effects on urothelial cell proliferation and a high sensitivity and specificity for IC/BPS symptoms and clinical findings. In this article, we review the urinary markers, possible future therapies for IC/BPS, and the clinical relevance and controversies regarding the diagnosis of IC/BPS.

Obstetric fistulae in West Africa: patient perspectives.

OBJECTIVE: The objective of this study is to gain insight into the nature of obstetric fistulae in Africa through patient perspectives. STUDY DESIGN: At l'Hôpital Saint Jean de Dieu in Tanguieta, Benin, 37 fistula patients underwent structured interviews about fistula cause, obstacles to medical care, prevention, and reintegration by 2 physicians via interpreters. RESULTS: The majority of participants (43%) thought their fistulae were a result of trauma from the operative delivery. Lack of financial resources (49%) was the most commonly reported obstacle to care, and prenatal care (38%) was most frequently reported as an intervention that may prevent obstetric fistulae. The majority (49%) of the participants requested no further reintegration assistance aside from surgery. CONCLUSION: Accessible emergency obstetric care is necessary to decrease the burden of obstetric fistulae in Africa. This may be accomplished through increased and improved health care facilities and education of providers and patients.

Neglected pessary causing a rectovaginal fistula: a case report.

BACKGROUND: Pessaries, properly maintained, have been shown to be safe for long-term care of symptomatic vaginal prolapse. Complications from neglected pessaries include impaction, erosion and fistula formation. Vesicovaginal fistulas have been described, but literature reports of rectovaginal fistulas are scarce. CASE: A 70-year-old woman, referred for pessary management, was found to have an impacted pessary that could not be removed due to pain. Examination under anesthesia revealed a Gellhorn pessary in the lumen of the rectum. It was removed transanally, leaving a large rectovaginal fistula. The patient was scheduled for reparative surgery in conjunction with colorectal surgery, but she cancelled the day before. CONCLUSION: For patients with a rectovaginal fistula resulting from an impacted vaginal pessary, a 2-stage procedure is required. The first stage, done under anesthesia, includes removal of the pessary and an examination to assess the size and location of the fistula. The second stage is operative management of the rectovaginal fistula, preceded by adequate bowel preparation. The clinician must stress proper pessary maintenance in order to avoid the serious consequences of a neglected pessary.

[Cost analysis in patients admitted with COPD in 2002]. / Analiza costurilor BPOC la pacientii internati.

UNLABELLED: The aim of the study was to assess the costs of hospital admission for COPD patients in a high level unit ("Marius Nasta" Institute of Pulmonology) in order to appreciate the financial burden of the disease. We analyzed retrospectively the medical charts of patients admitted between January and September 2002. 181 charts were included. We extracted data regarding the patient (age, sex, smoking habits, income), disease (duration, severity) and hospital admittance (number of days, tests performed, medication received). Data were processed in EpiInfo 6. RESULTS: mean duration of admittance was 17, 18 days. Mean cost of admittance was 25,448,348 lei (727 Euro), divided in: mean costs of the lab tests - 5,936,812 lei (170 Euro), mean cost of medication--4,428,000 lei (126 Euro), with obvious dominance of COPD medication: 4,310,022 lei; mean cost of hospital stay (including hotel, food and personnel expenses) was 15,120,094 lei (432 Euro). COPD severity was judged on the spirometry at discharge. Mean FEV1 was 45.66% of predicted value. According to GOLD, 10 pts (5.52%) were in stage I, 44 pts (24.3%) in stage II, 69 (38.12%) in stage III and 58 pts (32.03%) in stage IV. Costs per patient were similar for stages I, II and III and significantly higher for stage IV CONCLUSIONS: admitted COPD patients are in severe stages, with a long duration of admittance. Overall costs are much smaller than in Europe, more than half of these costs are due to hospital stay.