Robotic hysterectomy: technique and initial outcomes.

A surgical robot can move in ways that the human wrist cannot. Is it a practical substitute for the conventional hands-on approach?

Removal of pelvic leiomyomata and endometriosis five years after supracervical hysterectomy.

BACKGROUND: The number of laparoscopic supracervical hysterectomies performed has increased, yet the benefits and consequences are not well understood. CASE: The patient presented 5 years after a laparoscopic supracervical hysterectomy with pelvic pain, an elevated CA 125 level, and a pelvic mass. Surgical exploration revealed multiple leiomyomata with adenomyosis and endometriosis. CONCLUSION: After a laparoscopic supracervical hysterectomy, pelvic seeding of morcellated uterine tissue may lead to symptomatic pelvic leiomyomata and endometriosis requiring further surgery. Surgeons performing laparoscopic supracervical hysterectomies should take measures to prevent pelvic seeding at the time of morcellation and recognize the complication when it occurs.

Histological and biomechanical evaluation of implanted graft materials in a rabbit vaginal and abdominal model.

OBJECTIVE: The objective of the study was to describe the histologic and biomechanical changes of implanted dermal collagen graft materials. STUDY DESIGN: Twenty rabbits were randomized into 2 groups (6 and 12 weeks, respectively). Each rabbit had 4 graft segments (human dermis, porcine dermis, porcine collagen-coated polypropylene mesh, and autologous fascia) randomly implanted into the abdomen and the vagina. Biomechanical testing and histologic analysis was performed after recovery of graft segments. RESULTS: Dermal graft segments showed a marked decrease in ultimate strength (84% to 86%) and elastic modulus (73% to 82%) that was significantly different from the decrease seen in autologous fascia or coated synthetic mesh (P < .0008 and P < .0001, respectively). The decrease in ultimate strength was associated with vaginal implantation (P = .057). Dermal graft materials had moderate inflammation and minimal collagen infiltration. CONCLUSION: The mechanical properties of dermal graft materials decline after implantation. Vaginal implantation may cause a different tissue response to graft material than abdominal implantation. Dermal graft material caused moderate inflammation and minimal collagen ingrowth remote from implantation.

Removal of the retained cervical stump.

OBJECTIVE: The purpose of this study was to identify indications for and complications of abdominal or vaginal surgical removal of the cervical stump after previous supracervical hysterectomy. STUDY DESIGN: This was a retrospective chart review of trachelectomy patients at Mayo Clinic, Rochester, Minnesota, or Mayo Clinic, Scottsdale, Arizona, between January 1974 and December 2003. RESULTS: Of 335 patients with a history of supracervical hysterectomy who subsequently required trachelectomy, 25 were excluded from study. Half of the remaining 310 patients had trachelectomy between 1974 and 1983, an average of 26 years after hysterectomy. The indication in three quarters of trachelectomies performed vaginally was prolapse. The vaginal approach had significantly fewer complications than the abdominal approach. CONCLUSION: Removal of the cervical stump is infrequent and has declined over a 30-year period. The decline in trachelectomy may be because of a decreasing number of supracervical hysterectomies performed. When trachelectomy is performed vaginally, prolapse is the most common indication, and there are few complications.

Rectovaginal fistula after Posterior Intravaginal Slingplasty and polypropylene mesh augmented rectocele repair.

Posterior Intravaginal Slingplasty and mesh augmented rectocele repairs are procedures promoted for correction of vaginal relaxation. There is little data on the complications of these procedures alone or in combination. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented. A 60-year-old female developed a rectovaginal fistula 3 months after undergoing a Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for prolapse. Two attempts at correcting the fistula failed and there was a recurrence of her vault prolapse. She may now require diverting colostomy and repeat repair of her vault prolapse. The case report highlights the difficulties in treating a rectovaginal fistula that developed after Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for vaginal vault prolapse. More data regarding complications associated with use of these procedures is needed prior to widespread use.

Laparoscopic management of the adnexal mass.

Ovarian neoplasms are common in women of all ages. As many as 10% of women in the United States will undergo surgical removal of an adnexal mass sometime in their lifetime. Gynecologic surgeons have pioneered laparoscopic surgery, developing what was originally a diagnostic tool into a safe and effective approach to management of adnexal masses. Accumulating scientific data support the laparoscopic approach to the adnexal mass as the preferred treatment.

Long-term results of abdominal sacrocolpopexy.

OBJECTIVE: Our purpose was to determine the long-term results after abdominal sacrocolpopexy. STUDY DESIGN: Computer-coded procedure logs identified women who had an abdominal sacrocolpopexy performed from 1985 to 1992. Subjects answered a validated, condition-specific symptom questionnaire, a sexual function questionnaire, and a demographic survey. Failures were defined by reoperation or symptoms. The data were analyzed with use of the Student t test and the Fisher exact test. RESULTS: At the time of surgery the subjects (n=38) had a mean age of 59.2 years (range 40-77 years), parity 4.03 (1-9), BMI 26.5 (18.6-40.2), and stage of prolapse 2.56 (0-4). The mean follow-up interval was 13.7 years (10-17 years). The total number of failures was 10 (26.3%), 4 (10.5%) because of reoperation and 6 (16%) because of symptoms. Symptom distress scores were low and similar between failures and successes. Twelve subjects were available for examination and most defects were noted in the anterior wall. CONCLUSION: This long-term outcome analysis of abdominal sacrocolpopexy found the procedure to be durable with a 74% success rate at a mean follow-up of 13.7 years.