Vesicovaginal fistula following pelvic surgery: Our experiences and recommendations for diagnosis and prompt referral.

BACKGROUND: Vesicovaginal fistula (VVF) is an uncommon but known complication of pelvic surgery. Post-operative urine leakage should generate a high index of clinical suspicion for early diagnosis of VVF. AIMS: This study aims to identify areas for improvement and provide recommendations for timely and accurate diagnosis of VVF to minimise patient morbidity. MATERIALS AND METHODS: A retrospective observational study of all patients who underwent VVF repairs unrelated to malignancies in a ten-year period at two primary referral centres in Brisbane was performed to review the aetiology, performance of investigative tests and management of these cases. RESULTS: A total of 56 patients were studied with the identification of significant delays to diagnosis and referral, the performance of multiple unnecessary tests and low rates of primary surgeon referral. CONCLUSIONS: Early recognition of VVF and assessment by outpatient methylene blue dye test can provide quick same-day diagnosis and minimise patient suffering. We hope this will alert gynaecologists and provide guidelines for diagnosis and improved management to allow for prompt referral and repair of genitourinary fistula.

Laparoscopic transabdominal cerclage in pregnancy: A single centre experience.

BACKGROUND: Transabdominal cerclage can reduce the risk of preterm birth in women with cervical insufficiency. AIMS: This study evaluated outcomes following insertion of a laparoscopic transabdominal cerclage in pregnant women. MATERIALS AND METHODS: A retrospective observational study. PATIENTS: pregnant women who underwent laparoscopic transabdominal cerclage from 2011 to 2017. Eligible women had cervical insufficiency and were not suitable for a transvaginal cerclage. INTERVENTION: the insertion of a laparoscopic transabdominal cerclage in the pregnancy. MEASUREMENTS: neonatal survival, delivery of an infant at ≥34 weeks gestation and surgical morbidity were evaluated. RESULTS: Of 19 women who underwent laparoscopic transabdominal cerclage in pregnancy, at 6-11 weeks gestation, the perinatal survival rate was 100%. There were no complications. The average gestational age at delivery was 37.1 weeks. Sixteen women delivered after 34 weeks. CONCLUSIONS: Laparoscopic transabdominal cerclage is a safe and effective procedure in women with poor obstetric histories. It requires the correct skill, expertise and patient selection.

Laparoscopic transabdominal cerclage: Outcomes of 121 pregnancies.

BACKGROUND: Cervical insufficiency is a significant cause of morbidity and mortality. Cervical cerclage is one option in the management of cervical insufficiency. AIM: To evaluate obstetric outcomes following insertion of a pre-pregnancy laparoscopic transabdominal cerclage in women at high risk for pre-term labour and/or mid-trimester pregnancy loss. METHODS: A prospective observational study of consecutive women who underwent laparoscopic transabdominal cerclage from 2007 to 2017. Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix and were considered not suitable for a transvaginal cerclage. The primary outcome was neonatal survival and the secondary outcome was delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated. RESULTS: During the study period, 225 women underwent laparoscopic transabdominal cerclage. We present the outcomes of 121 pregnancies resulting in 125 babies. The perinatal survival rate of viable pregnancies was 98.5% with a mean gestational age at delivery of 35.2 weeks; 79.7% of babies were delivered at ≥34.0 weeks gestation. CONCLUSION: Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. For optimal success the procedure requires the correct surgical expertise, equipment and appropriate patient selection.

Laparoscopic Resection of Cesarean Scar Ectopic Pregnancy.

STUDY OBJECTIVE: To demonstrate a technique for the laparoscopic surgical management of cesarean section scar ectopic pregnancy. DESIGN: Step-by-step presentation of the procedure using video (Canadian Task Force classification III). SETTING: Cesarean section scar ectopic pregnancy is a rare form of ectopic pregnancy with an incidence ranging from 1:1800 to 1:2216. Over the last decade, the incidence seems to be on the rise with increasing rates of cesarean deliveries and early use of Doppler ultrasound. These pregnancies can lead to life-threatening hemorrhage, uterine rupture, and hysterectomy if not managed promptly. Local or systemic methotrexate therapy has been used successfully but can result in prolonged hospitalization, requires long-term follow-up, and in some cases treatment can fail. In the hands of a trained operator, laparoscopic resection can be performed to manage this type of pregnancy. PATIENT: Consent was obtained from the patient, and exemption was granted from the local Internal Review Board (The Womens' Hospital, Parkville). INTERVENTIONS, MEASUREMENTS AND MAIN RESULTS: In this video we describe our technique for laparoscopic management of a cesarean scar ectopic pregnancy. We present the case of a 34-year-old G4P2T1 with the finding of a live 8-week pregnancy embedded in the cesarean section scar. The patient had undergone 2 previous uncomplicated cesarean sections at term. On presentation her ß-human chorionic gonadotropin (ß-hCG) level was 52 405 IU/L. She was initially managed with an intragestational sac injection of potassium chloride and methotrexate, followed by 4 doses of intramuscular methotrexate. Despite these conservative measures, the level of ß-hCG did not adequately fall and an ultrasound showed a persistent 4-cm mass. A decision was made to proceed with surgical treatment in the form of a laparoscopic resection of the ectopic pregnancy. The surgery was uneventful, and the patient was discharged home within 24 hours of her procedure. Her serial ß-hCG levels were followed until complete resolution. CONCLUSION: Laparoscopic excision of cesarean section scar ectopic pregnancy is an effective procedure for the management of this increasingly more common condition. The use of vasopressin intraoperatively and laparoscopic suturing can prevent hemorrhage and allow for the safe removal of the ectopic pregnancy with multilayer repair of the uterine defect.