The Batalha Clitoropexy: Shortening an Elongated Clitoris - A Minimally Invasive Technique.

BACKGROUND: Female cosmetic genital surgery is becoming increasingly sought after by women who are concerned with the appearance of their vulva. Labiaplasty for the labia minora is undoubtedly the most commonly performed female cosmetic genital surgery. However, an increasing number of patients seen in our clinics in both Brazil and the United States are presenting with clitoral hypertrophy, specifically clitoral elongation. The elongated clitoris will usually protrude beyond the labia minora and majora and from the patient's perspective will give a less feminine appearance as they will often describe the protruding clitoris as feeling like they have a small penis. The surgical technique described here, Batalha Clitoropexy, is a minimally invasive surgical technique for clitoral length-reduction that does not require amputation or debulking. This technique is presented in the form of the detailed sequential steps needed to achieve satisfactory results. Photos taken before and after the procedure in a representative case show that the clitoral length has been shortened from 5.0 cm to 1.5 cm without the need of an invasive amputation or debulking clitoroplasty. Many patients with clitoromegaly or an elongated protruding clitoris do not need to undergo an invasive clitoroplasty. Specifically, patients with clitoral elongation or clitoral ptosis can be surgically treated with a less-invasive clitoropexy surgical procedure which can restore normal anatomic position to treat a protruding clitoris.

The Novel Use of Bipolar Radiofrequency Microneedling in the Treatment of Lichen Sclerosus.

INTRODUCTION: Lichen sclerosus (LS) is a chronic, distressing, inflammatory process that has a huge impact on quality of life in women. Uncontrolled vulvar LS can lead to chronic symptoms of itching and pain and can lead to anatomic changes, scarring, and elevated risk of cancer. First-line therapy with corticosteroids is often not successful in controlling symptoms, especially over the long term. This is the first study to review the effects of bipolar radiofrequency (RF) with microneedling to treat the vaginal and vulvar symptoms of LS. MATERIALS AND METHODS: This retrospective study was initiated due to the recognition of improvement in vulvar skin condition and resolution of lichen sclerosus symptoms in patients who had already failed traditional treatment and underwent radio frequency with microneedling procedures of the vulva, perineum, and perianal regions. Patients were treated with three treatments of bipolar RF and bipolar RF with microneedling four to eight weeks apart. Patient questionnaires were used to assess improvement in the symptoms of LS including itching, tearing of tissue, changes in the appearance and color of tissue, and dryness of skin and mucosa. RESULTS: The data from the questionnaires showed a significant reduction or complete resolution in these symptoms, with 86% of the patients reporting either significant or complete resolution. In the case of itching, which is typically one of the most severe symptoms of LS, 91% of patients reported significant or complete resolution. 87% of patients reported symptom resolution lasting at least six months, with 39% of the patients having results lasting 12 months or more before recurrence. Recurrences can be retreated on an as-needed basis or with annual maintenance therapy consisting typically of just one treatment. CONCLUSION: Radiofrequency with microneedling treatments for persistent LS showed significant improvement in LS symptoms. As LS is a chronic recurring condition, the treatment protocol resulted in high patient satisfaction for these women who had not experienced these results in terms of amount of symptom resolution or duration of symptom resolution with prior treatments using topical steroid cream or other modalities.

Diffuse skeletal muscle extramedullary plasmacytomas: a rare case and review of the literature.

Extramedullary plasmacytomas are rare neoplasms arising from proliferations of monoclonal plasma cells. In primary form, these malignancies occur without other sites of plasma cell disease. Secondary extramedullary plasmacytomas occur in association with multiple myeloma and may be discovered during initial intramedullary disease or may occur during multiple myeloma relapse. In very rare instances, secondary extramedullary plasmacytomas have multifocal skeletal muscle involvement. We present a case of multifocal skeletal muscle plasmacytomas in a 58-year-old man with shoulder-reduced range of motion, pain, and a history of previously treated multiple myeloma. To our knowledge, the patient's unique relapse presentation of torso and shoulder soft tissue masses and the vast extent of skeletal muscle involvement are unique to cases in the current literature. This case also has MRI findings of a muscular plasmacytoma with internal hemorrhage which has not been previously reported. This case report will review imaging features and clinical presentations of intramuscular extramedullary plasmacytomas. Since imaging surveillance for multiple myeloma relapse is commonly performed, radiologists should be aware of these uncommon relapsing features including multifocal intramuscular masses which may contain internal hemorrhage.

Indications and Complications Associated with the Removal of 506 Pieces of Vaginal Mesh Used in Pelvic Floor Reconstruction: A Multicenter Study.

STUDY OBJECTIVE: Synthetic mesh utilized to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can often result in postoperative complications. The objectives of this study were to determine: 1) the most common indications for mesh removal; 2) the incidences of the removal of specific mesh procedures (such as suburethral sling [SUS], transvaginal mesh [TVM], or sacrocolpopexy); and 3) the idences and types of surgical complications associated with mesh removal. DESIGN: This was a retrospective study. Design Classification: Canadian Task Force II-3. SETTING: Three tertiary referral centers in the United States. PATIENTS: We examined data from all patients at the three centers who underwent surgical removal of synthetic materials from previous SUS, TVM, and sacrocolpopexy procedures for mesh-related complications from 2011 to 2013. INTERVENTION: Patients underwent vaginal, intra-abdominal, and inguinal mesh revisions by cutting, partial removal, or total removal of the mesh for mesh-related complications. MEASUREMENTS AND RESULTS: Overall, 445 patients with complications underwent mesh removal laparoscopically, via groin dissection and/or transvaginally. There were a total of 506 mesh products removed. Of these, 56.5% were slings and 43.5% were for pelvic organ prolapse (POP). Synthetic mesh removed from patients included: transvaginal mesh (TVM) anterior for anterior vaginal prolapse, TVM posterior for posterior vaginal prolapse, sacrocolpopexy mesh, and suburethral slings (SUS) for stress urinary incontinence. Synthetic SUS removed included: retropubic (RPS), transobturator (TOT), and single-incision slings (SIS). TOT was the most common type of sling removed. Patients with a sling who only complained of vaginal pain with or without intercourse underwent a vaginal approach for surgical revision/removal of the sling (86.6%). Patients with an RPS with lower abdominal/suprapubic pain and vaginal pain underwent a vaginal and laparoscopic approach for sling removal (18.4%). Patients with a TOT sling who complained of vaginal and groin pain underwent a vaginal and inguinal approach for sling removal (4.3%). In patients who had POP mesh removal, 42.3% had an anterior TVM, 30.6% had a posterior TVM, 14% had both anterior and posterior TVMs, and 13.1% underwent sacrocolpopexy mesh removal. Complications encountered during mesh revision/removal surgery were: two blood transfusions from complete RPS removal (vaginal and laparoscopic approach), three urethral injuries during TOT sling removal (vaginal approach), two ureteral injuries during anterior vaginal wall mesh removal, and two rectal injuries during posterior vaginal wall mesh removal. All injuries were repaired at the time of mesh removal without recurrence. CONCLUSION: In our study, the most common indication for mesh removal was pain with or without intercourse. The most common mesh procedure resulting in removal was the TOT sling. Use of a vaginal approach only for sling removal had the lowest incidence of intraoperative complications. Laparoscopic RPS removal had the highest incidence of required blood transfusions, anterior TVM had the highest incidence of ureteral injury, and posterior TVM had the highest incidence of rectal injury. Overall, sling, TVM, and sacrocolpopexy mesh removal are safe procedures when performed by experienced surgeons.

Laparoscopic Repair of Enterocervical Fistula After Mesh Erosion Into the Sigmoid Colon and Cervix After Robotic Supracervical Hysterectomy and Sacrocervicopexy.

OBJECTIVES: To discuss risk factors and describe laparoscopic management of an unusual late complication of sacrocolpopexy mesh erosion resulting in enterocervical fistula after supracervical hysterectomy and robotic sacrocervicopopexy. CASE: We report on a unique case of a long-term mesh complication after robotic supracervical hysterectomy and polypropylene mesh sacrocervicopexy. Four years after the procedure, the patient was found to have mesh extrusion through the cervical os as well as mesh erosion into the sigmoid colon with a connecting enterocervical fistula. CONCLUSIONS: A laparoscopic approach was used successfully to address the complications. The case is unique because of the success of minimally invasive surgery in its management and multiple sites of erosion with a connecting fistula.

The IUGA/ICS classification of synthetic mesh complications in female pelvic floor reconstructive surgery: a multicenter study.

INTRODUCTION AND HYPOTHESIS: The objective was to report patterns of sling and transvaginal mesh-related complications using the IUGA/ICS classification of prosthesis-related complications. METHODS: This was a retrospective chart review of all patients who underwent surgical removal of sling, transvaginal mesh, and sacrocolpopexy for mesh-related complications from 2011 to 2013 at three tertiary referral centers. The International Urogynecological Association (IUGA)/International Continence Society (ICS) classification system was utilized. RESULTS: We identified 445 patients with mesh complications, 506 pieces of synthetic mesh were removed, and 587 prostheses-related complications were classified. 3.7 % of patients had viscus organ penetration or vaginal exposure as their presenting chief complaint and 59.7 % were classified as not having any vaginal epithelial separation or category 1. The most common category was spontaneous pain (1Be: 32.5 %) followed by dyspareunia (1Bc: 14.7 %). The sling group was 20 % more likely to have pain compared with the pelvic organ prolapse (POP) mesh group (OR 1.2, 95 % CI 0.8-1.6). The most commonly affected site (S2) was away from the suture line (49 %). Compared with the sling group, the POP group had a higher rate of mesh exposure, which mostly occurred at the suture line area. The majority of patients presented with mesh-related complications more than 1 year post-insertion (T4; average 3.68 ± 2.47 years). CONCLUSION: Surgeons should be aware that patients with vaginal mesh complications routinely exhibit complications more than 1 year after the implantation with pain as the most common presenting symptom.

Laparoscopic Paravaginal Defect Repair: Surgical Technique and a Literature Review.

Paravaginal defects, commonly seen in patients with anterior vaginal wall prolapse, are due to the detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment. The majority of anterior vaginal wall prolapse is thought to be caused by paravaginal defects. Richardson et al. first described and demonstrated the anatomy of the paravaginal defect, as well as described the initial technique of the abdominal approach to repair. Since that time, the laparoscopic approach for repair has been developed and described with success rates of laparoscopic paravaginal defect repair reported in the range of 60% to 89%. This minimally invasive approach to address anterior wall prolapse eliminates the need for a vaginal incision, reduces risk of vaginal shortening and can be completed at the same time as other laparoscopic procedures, such as hysterectomy, sacralcolpopexy, and/or Burch Urethropexy. Compared to the open abdominal approach, there is improved visualization, less risk of bleeding, and faster recovery with the laparoscopic method. Compared to an anterior colporrhaphy, laparoscopic paravaginal repair is a much more anatomic repair of lateral defects and does not result in vaginal shortening. The laparoscopic paravaginal repair should be considered as the first-line treatment of anterior vaginal wall prolapse caused by lateral defects, including at time of laparoscopic/robotic sacralcolpopexy.

Elevate and Uterine Preservation: Two-Year Results.

OBJECTIVE: To evaluate efficacy of the Elevate Anterior and Apical (EAA) in the repair of pelvic organ prolapse (POP) when performed after previous hysterectomy and with or without uterine preservation during POP surgery. MATERIALS AND METHODS: One hundred forty-two women with anterior vaginal prolapse and/or apical descent ≥ stage II were enrolled. The primary outcome was treatment failure defined as > stage II POP-Q during follow-up using the Last observed Failure Carried Forward method. Three sub-groups were analysed: baseline previous hysterectomy (N = 61); concomitant hysterectomy (N = 29), and preserved uterus/no hysterectomy (N = 51). Demographics, primary and secondary outcomes, and extrusion were compared between the groups. A P value less than 0.05 was considered statistically significant. RESULTS: Anatomic success shows significant and durable improvement at 24 months. The success for the apical compartment ranged between 93.8% and 100%. Success was slightly lower for the anterior compartment (70.8-89.1%). No statistically significant difference between the 3 subgroups. Age was the only patient characteristic to be found different between the 3 subgroups. In addition, there was no difference in overall intraoperative complications (P = 0.263). Mesh extrusion was found in all groups: 3 of 61 (4.9%) had previous hysterectomy; 4 of 29 (13.8%) had concomitant hysterectomy; and 1 of 51 (2.0%) had uterus preserved (P = 0.094). There appears to be a trend toward higher extrusion when a hysterectomy was performed with the EAA. CONCLUSIONS: Anatomic success and complications for the EAA do not appear to be significantly impacted when the uterus is removed before or during surgery or preserved. There may be a trend toward increased mesh extrusion when a hysterectomy is performed. However, larger cohort studies are needed to determine if concomitant hysterectomy impact extrusion.

Laparoscopic and Robotic-assisted Vesicovaginal Fistula Repair: A Systematic Review of the Literature.

Two types of laparoscopic or robotic-assisted vesicovaginal fistula (VVF) repairs, the traditional transvesical (O'Conor) and extravesical techniques, dominate the literature. The objectives of this study are to compare success rates between laparoscopic or robotic transvesical and extravesical laparoscopic VVF repair techniques and to evaluate the impact of the number of layers in the closure, interposition flaps, and intraoperative testing of the integrity of the bladder repair. Eligible studies, published between 1994 and March 10, 2014, were retrieved through Medline and bibliography searches. All study designs of laparoscopic/robotic VVF repair were included. Open laparotomy and vaginal approaches were excluded. Only 1 retrospective cohort study was included, with the remaining articles consisting of case reports and case series. Ultimately, only 44 studies were included in a systematic review: 9 articles of robotic-assisted approach, 3 laparoscopic single-site surgeries, and 32 conventional laparoscopic approaches. A literature review revealed a balanced number of reports for both transvesical and extravesical approaches. Statistical meta-analysis was not performed because of high heterogeneity. The overall success rate of laparoscopic VVF repair was 80% to 100% with a follow-up period of 1 to 74 months. The success rate of transvesical and extravesical techniques were 95.89% and 98.04% (relative risk, .98; 95% confidence interval, .94-1.02). There was no statistical difference in success rates of VVF repair with different number of layers in the fistula closure or with use of interposition flaps, but there was a small increase in success in the cases that documented intraoperative bladder filling to test the integrity of the bladder closure. In conclusion, transperitoneal extravesical VVF repair has cure rates similar to the traditional transvesical approach. Laparoscopic extravesical VVF repair is a safe, effective, minimally invasive technique with excellent cure rates similar to those of the conventional transvesical approach in experienced surgeons' hands.

The 26-Minute Laparoscopic Sacral Colpopexy: Do We Really Need Robotic Technology?

STUDY OBJECTIVES: To demonstrate the technical steps of a laparoscopic sacral colpopexy (LSC), demonstrate the efficiency of LSC, review the comparative LSC and robotic-assisted sacral colpopexy (RSC) literature, and challenge surgeons' conventional wisdom regarding RSC. DESIGN: Use of a time-stamped video with a step-by-step explanation of the technique and slides of comparative trials and benefits of robotic surgery. SETTING: Sacral colpopexy remains the gold standard surgical procedure for treating vaginal vault prolapse. It can be performed via laparotomy, laparoscopically with or without robotic assistance. Robotic technology has been marketed based on unsubstantiated claims, including better visualization, smaller incisions, less blood loss, and greater efficiency. Conventional wisdom suggests that robotic-assisted laparoscopic surgery is easier and thus faster for the practicing surgeon. INTERVENTION: A time-stamped video of LSC in a woman with vaginal vault prolapse was performed in 26 minutes using 14 sutures in the vagina and 2 sutures in the presacral ligament. The stopwatch began after placement of the scope in the abdomen and before placement of the 3 accessory posts and ended with peritoneal closure over the sacral colpopexy mesh. The patient signed a consent and release form for the use of her video for educational purposes. CONCLUSION: A review of the literature suggests that the average RSC takes 260 minutes; the average is 200 minutes with the conventional LSC technique, realizing a time savings of at least 60 minutes. Our 26-minute LSC supports this finding.

Obturator Neuralgia: A Rare Complication of Tension-free Vaginal Tape Sling-Complete Resolution After Laparoscopic Tension-free Vaginal Tape Removal.

STUDY OBJECTIVE: To show a technique of retropubic tension-free vaginal tape (TVT) removal using both a transvaginal and laparoscopic approach in the treatment of a rare condition, obturator neuralgia. DESIGN: A step-by-step explanation of the patient's condition, diagnosis, surgical technique, and postoperative results using video, pictures, and medical illustrations (education video). SETTING: TVT retropubic slings have become the gold standard for the treatment of stress urine incontinence over the last decade. Despite high cure rates, the TVT is not without potential complications. Typical complications include urine retention, incomplete bladder emptying, frequency, urgency, urethral erosion, vaginal extrusion, vaginal pain, and dyspareunia. The most common complication for sling removal/revision is chronic pain. The TVT obturator neuralgia is a rare and specific type of chronic pain that is normally associated with transobturator tape slings. The purpose of this video is to present an extremely rare complication of TVT retropubic slings, present symptoms and signs of obturator nerve compression, show the normal and the actual position of this patient's TVT sling, describe the laparoscopic removal of the TVT sling, and present the postoperative course and resolution of the patient's pain. The patient signed a release for her video to be used for educational and teaching purposes. INTERVENTION: A combined transvaginal and laparoscopic approach in a patient with lower abdominal, levator, and obturator-type pain after a TVT retropubic procedure. CONCLUSION: In patients suffering from obturator neuralgia after a retropubic sling, surgeons should include the sling as a potential causative factor in the differential diagnosis. Surgeons should consider removing the sling based on the patient's symptoms. If the patient suffers from only vaginal pain and dyspareunia, then the surgeon should consider only the removal of the vaginal portion of the sling. In patients with obturator neuralgia, retropubic, and/or lower abdominal pain, one should consider a combined transvaginal and laparoscopic approach in an attempt to remove the majority of the sling and release tension between 2 points of fixation.

Laparoscopic extravesical vesicovaginal fistula repair: our technique and 15-year experience.

INTRODUCTION AND HYPOTHESIS: Two types of laparoscopic vesicovaginal fistula (VVF) repairs, the traditional transvesical (O'Conor) and extravesical techniques, dominate the literature. We present our 15-year experience of primary and recurrent cases of VVF utilizing an extravesical technique, which we first described in 1999. METHODS: An IRB approved retrospective study revealed 44 female patients with either primary or recurrent VVF. Laparoscopic extravesical repair was performed without an omental flap in the majority of cases. A three-layer closure technique was performed utilizing a double-layer bladder closure and a single-layer vaginal closure followed by bladder testing. A suprapubic catheter was utilized for 2-3 weeks postoperatively for bladder decompression. RESULTS: A review of our experience reveals a 97 % (32 out of 33) cure for primary VVF and 100 % (11 out of 11) rate for recurrent fistulas, with an overall cure rate of 98 % (43 out of 44) at a mean follow-up of 17.3 months (range 3-64). An omental flap was not utilized in 98 % of patients (43 out of 44), with a success rate of 98 % (42 out of 43). The mean estimated blood loss was 39 mL (range 0-450), mean hospital stay was 1.1 days (range 1-3), and none of the patients suffered any major intra- or postoperative complications. None of the patients required a conversion to open laparotomy. CONCLUSIONS: Based upon our experience we believe that performing laparoscopic extravesical VVF repair using a three-layer closure technique without an interposition omentum is a safe, effective, minimally invasive technique with excellent cure rates in an experienced surgeon's hands.

Laparoscopic transperitoneal extravesical approach to vesicovaginal fistula repair without omental flap: a novel technique.

INTRODUCTION AND HYPOTHESIS: The O'Connor bladder bivalving technique remains the traditional abdominal approach to vesicovaginal fistula repair whether performed via laparotomy or laparoscopy. METHODS: This video depicts a new surgical technique utilizing a laparoscopic transperitoneal extravesical approach without invasive bladder bivalving or an omental flap. This technique was first described in 1999 and has been utilized on >40 patients with either primary or recurrent vesicovaginal fistulas. RESULTS: A 98% success rate is reported. CONCLUSION: This alternative technique can be performed using either a laparoscopy or the traditional laparotomy approach.

Evaluation of sexual function outcomes in women undergoing vaginal rejuvenation/vaginoplasty procedures for symptoms of vaginal laxity/decreased vaginal sensation utilizing validated sexual function questionnaire (PISQ-12).

Sexual function outcomes were analyzed in a group of women (n = 78) presenting for vaginal rejuvenation/vaginoplasty procedure for a chief complaint of vaginal laxity and decreased sensation with intercourse. Outcomes were analyzed utilizing the validated Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) before and at least 6 months after repair with vaginal rejuvenation/vaginoplasty procedure (VR). Mean age was 43.6 ± 7.9 (range 25-62), and 19 patients (24.3%) were found to have prolapse at time of initial exam and underwent vaginal vault suspension in addition to VR. Compared preoperatively and postoperatively, the overall sexual function (Total PISQ-12) statistically improved (30.3 ± 6.6 vs. 38.2 ± 5.2, P < 0.001). All individual scores statistically improved except in 3 categories in which there was no change (Q1-desire, Q5-pain, and Q11- partner premature ejaculation). Overall sexual satisfaction improved as well as subcategories of increased sexual excitement during intercourse and overall increase in intensity of orgasms. Pain with intercourse subscores were found to be no different from preoperatively to postoperatively. Previous studies have shown that sexual function improves with repair of prolapse; however, this is the first study to show improved function using a validated questionnaire in patients undergoing VR for laxity.

Laparoscopic mesh sacrohysteropexy with concurrent laparoscopic myomectomy for treatment of multiple myomas: case report and literature review.

Conservative surgical management of uterine prolapse with uterine conservation has become an alternative treatment in women who wish to maintain their uterus. Vaginal and abdominal approaches for uterine suspension have been described and reported. Certain concomitant pathologic conditions of the uterus such as uterine myomas have been considered in some patients to be a contraindication to conservative surgery. Herein we report the case of a 55-year-old woman with symptomatic uterine prolapse with multiple myomas who desired uterine preservation and was successfully treated via laparoscopic myomectomy and laparoscopic mesh sacrohysteropexy.

Surgically shortened vagina lengthened by laparoscopic Davydov procedure.

BACKGROUND: The laparoscopic Davydov procedure is a neovagina surgical technique most commonly used in patients with vaginal agenesis. We present a unique case of vaginal length restoration using this procedure in a patient with vaginal shortening after multiple vaginal surgeries. CASE: A 62-year-old patient presented to our office after multiple vaginal surgeries with symptoms suggestive of cystocele, rectocele, vaginal vault prolapse, and dyspareunia. Excessive vaginal shortening and a painful vaginal apex were also noted upon initial examination. A laparoscopic Davydov procedure was performed to lengthen the vagina and to eliminate the apical pain. CONCLUSION: The laparoscopic Davydov procedure is a surgical option for patients with surgically shortened vaginas and dyspareunia.

Laparoscopic Davydov correction of a failed gracilis flap neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome with a pelvic kidney.

The laparoscopic Davydov procedure is a surgical technique for creation of a neovagina in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) or vaginal agenesis. Herein we report its use in creating a neovagina after failure of a previous surgical attempt in a patient with a pelvic kidney, which has not been described to date. The patient, a 28-year-old woman with MRKH in whom creation of a neovagina using bilateral gracilis flaps had been attempted, was unable to have intercourse because of a shortened and scarred vagina. We successfully used the laparoscopic Davydov procedure to create a functional neovagina despite the previous surgery and the presence of a pelvic kidney. The Davydov procedure is an option for use in patients with MRKH with history of unsuccessful neovaginal surgery and can be performed in the presence of a pelvic kidney.

Elevate anterior/apical: 12-month data showing safety and efficacy in surgical treatment of pelvic organ prolapse.

OBJECTIVE: This study aimed to assess the safety and efficacy of the Elevate Anterior/Apical transvaginal mesh procedure in pelvic organ prolapse (POP) repair at 12-months follow-up. METHODS: This prospective, multicenter, multinational study enrolled 142 patients experiencing anterior vaginal prolapse with or without apical descent (POP-Q ≥ stage II). Each patient received a single-incision transvaginal polypropylene mesh implantation anchored to the sacrospinous ligaments bilaterally. Primary outcome was treatment success defined as POP-Q less than or equal to stage I at 1 year using the Last Failure Carried Forward method. Secondary outcomes included validated quality-of-life measures. Fourteen subjects who received a concomitant posterior apical support procedure were excluded from the analysis. RESULTS: Of the 128 subjects, 112 (87.5%) completed the 12-months follow-up. The mean age was 64.7 years. The anatomic success rate was 87.7% (95% confidence interval, 80.3%-93.1%) for the anterior compartment and 95.9% (95% confidence interval, 88.5%-99.1%) for the apical compartment. POP-Q measurements (Aa, Ba, and C) improved significantly (P < 0.001) with no significant changes to TVL (P = 0.331). Related adverse events reported at greater than 2% were mesh exposure (8; 6.3%), urinary tract infection (7; 5.5%), transient buttock pain (5; 3.9%), de novo stress incontinence (5; 3.9%), retention (5; 3.9%), dyspareunia (3; 3.2%), and hematoma (3; 2.3%). All quality-of-life scores significantly improved from baseline (P < 0.001). CONCLUSIONS: Twelve-month data show that Elevate Anterior/Apical support procedure completed through a single vaginal incision yields favorable objective and subjective outcomes.

Two-year evaluation of the MiniArc in obese versus non-obese patients for treatment of stress urinary incontinence.

OBJECTIVES: Obesity is a well-established risk factor of stress urinary incontinence, which affects up to 35% of adult women worldwide. We evaluated whether there is a difference in outcomes with MiniArc sling for treatment of stress incontinence in obese women versus non-obese women at 24 months. METHODS: A 2-year subanalysis of obese (body mass index >30 kg/m(2) ) versus non-obese patients enrolled into a multicenter, prospective study evaluating the effectiveness of MiniArc sling was carried out. Qualitative (Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7) and quantitative measurements, including the cough stress test, were carried out. Secondary outcome measures included procedure time, estimated blood loss, length of stay, perioperative complications, Wong-Baker Faces Pain Scale and adverse events. RESULTS: Of 188 patients, 62 were obese. The mean procedure time, blood loss and length of stay were no different between groups. Obese patients reported significantly more pain immediately postoperatively (2 vs 1, Wong-Baker, P = 0.042), but there was no difference at postoperative day 7. There was no difference in objective cure using the cough stress test (81% obese vs 86% non-obese; P = 0.449). Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7 median scores showed no difference between groups in improvement (P = 0.126 and P = 0.087, respectively). No serious device-related complications were reported in either group. CONCLUSIONS: The MiniArc sling represents a safe and effective treatment option for both obese and non-obese patients with stress incontinence. Comparable outcomes at 2 years can be obtained in terms of cure rates using the cough stress test or questionnaires, as well as complication rates.

Failed omental flap vesicovaginal fistula repair subsequently repaired laparoscopically without an omental flap.

BACKGROUND: Conventional wisdom suggests that vascular interposition flaps are helpful in the treatment of all patients with vesicovaginal fistulas. Complicated fistulas are often treated with interposition omental flaps; however, failed omental flap repairs have not been described without the use of another interposition flap. CASE: A 52-year-old woman with a history of cystotomy repair at the time of hysterectomy and a subsequent abdominal omental flap vesicovaginal fistula repair failure underwent a successful repair using a laparoscopic-layered closure of her fistula without omental flap. CONCLUSION: A failed omental flap vesicovaginal fistula repair can be repaired laparoscopically and without an omental flap.