First sacral nerve and anterior longitudinal ligament anatomy: clinical applications during sacrocolpopexy.

BACKGROUND: The recommended location of graft attachment during sacrocolpopexy is at or below the sacral promontory on the anterior surface of the first sacral vertebra. Graft fixation below the sacral promontory may potentially involve the first sacral nerve. OBJECTIVE: The objectives of this study were to examine the anatomy of the right first sacral nerve relative to the midpoint of the sacral promontory and to evaluate the thickness and ultrastructural composition of the anterior longitudinal ligament at the sacral promontory level. STUDY DESIGN: Anatomic relationships were examined in 18 female cadavers (8 unembalmed and 10 embalmed). The midpoint of the sacral promontory was used as reference for all measurements. The most medial and superior point on the ventral surface of the first sacral foramen was used as a marker for the closest point at which the first sacral nerve could emerge. Distances from midpoint of sacral promontory and the midsacrum to the most medial and superior point of the first sacral foramen were recorded. The right first sacral nerve was dissected and its relationship to the presacral space was noted. The anterior longitudinal ligament thickness was examined at the sacral promontory level in the midsagittal plane. The ultrastructural composition of the ligament was evaluated using transmission electron microscopy. Height of fifth lumbar to first sacral disc was also recorded. Descriptive statistics were used for data analyses. RESULTS: Median age of specimens was 78 years and median body mass index was 20.1 kg/m2. Median vertical distance from midpoint of sacral promontory to the level of the most medial and superior point of the first sacral foramen was 26 (range 22-37) mm. Median horizontal distance from the midsacrum to the first sacral foramen was 19 (range 13-23) mm. In all specimens, the first sacral nerve was located just behind the layer of parietal fascia covering the piriformis muscle, and thus, outside the presacral space. Median anterior longitudinal ligament thickness at the sacral promontory level was 1.9 (range 1.2-2.5) mm. Median fifth lumbar to first sacral disc height was 16 (8.3-17) mm. CONCLUSION: Awareness of the first sacral nerve position, approximately 2.5 cm below the midpoint of the sacral promontory and 2 cm to the right of midline, should help anticipate and avoid somatic nerve injury during sacrocolpopexy. Knowledge of the approximate 2-mm thickness of the anterior longitudinal ligament should help reduce risk of discitis and osteomyelitis, especially when graft is affixed above the level of the sacral promontory.

Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study.

BACKGROUND: Reported rates of gluteal pain after sacrospinous ligament fixation range from 12-55% in the immediate postoperative period and from 4-15% 4-6 weeks postoperatively. The source of gluteal pain often is attributed to injury to the nerve to levator ani or pudendal nerve. The inferior gluteal nerve and other sacral nerve branches have not been examined thoroughly as potential sources of gluteal pain. OBJECTIVES: The purpose of this study was to further characterize anatomy of the inferior gluteal nerve and other nerves that are associated with the sacrospinous ligament from a combined gluteal and pelvic approach and to correlate findings to sacrospinous ligament fixation. STUDY DESIGN: Dissections were performed in female cadavers that had not been embalmed with gluteal and pelvic approaches. From a pelvic perspective, the closest structure to the superior border of the sacrospinous ligament midpoint was noted, and the sacral nerves that perforated the ventral surface of coccygeus muscle were examined. From a gluteal perspective, the closest distances from ischial spine to the pudendal, inferior gluteal, posterior femoral cutaneous, and sciatic nerves were measured. In addition, the closest distance from the midpoint of sacrospinous ligament to the inferior gluteal nerve and the origin of this nerve were documented. The thickness and height of the sacrospinous ligament at its midpoint were measured. Sacral nerve branches that coursed between the sacrospinous and sacrotuberous ligaments were assessed from both a pelvic and a gluteal approach. Descriptive statistics were used for data analysis. RESULTS: Fourteen cadavers were examined. From a pelvic perspective, the closest structure to the superior border of sacrospinous ligament at its midpoint was the S3 nerve (median distance, 3 mm; range, 0-11 mm). Branches from S3 and/or S4 perforated the ventral surface of coccygeus muscles in 94% specimens. From a gluteal perspective, the closest structure to ischial spine was the pudendal nerve (median distance, 0 mm; range, 0-9 mm). Median closest distance from inferior gluteal nerve to ischial spine and to the midpoint of sacrospinous ligament was 28.5 mm (range, 6-53 mm) and 31.5 mm (range, 10-47 mm), respectively. The inferior gluteal nerve arose from dorsal surface of combined lumbosacral trunk and S1 nerves in all specimens; a contribution from S2 was noted in 46% of hemipelvises. At its midpoint, the sacrospinous ligament median thickness was 5 mm (range, 2-7 mm), and its median height was 14 mm (range, 3-22 mm). In 85% of specimens, 1 to 3 branches from S3 and/or S4 nerves pierced or coursed ventral to the sacrotuberous ligament and perforated the inferior portion of the gluteus maximus muscle. CONCLUSIONS: Damage to the inferior gluteal nerve during sacrospinous ligament fixation is an unlikely source for postoperative gluteal pain. Rather, branches from S3 and/or S4 that innervate the coccygeus muscles and those coursing between the sacrospinous and sacrotuberous ligaments to supply gluteus maximus muscles are more likely to be implicated. A thorough understanding of the complex anatomy surrounding the sacrospinous ligament, limiting depth of needle penetration into the ligament, and avoiding extension of needle exit or entry point above the upper extent of sacrospinous ligament may reduce nerve entrapment and postoperative gluteal pain.

Trainee Perspectives Regarding the Effect of the Dobbs v. Jackson Women's Health Organization Supreme Court Decision on Obstetrics and Gynecology Training.

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

Preoperative Simulation of Retropubic Midurethral Sling to Decrease Bladder Perforation Rate Among Obstetrics and Gynecology Residents.

IMPORTANCE: Bladder perforation is an often avoidable complication of retropubic midurethral sling procedures. Bladder injury rates decrease with surgeon experience, but literature on techniques to train novice surgeons is limited. OBJECTIVE: Our objective was to decrease the bladder perforation rate among obstetrics and gynecology residents during retropubic midurethral sling procedures through implementation of an instructional video and low-fidelity simulation. STUDY DESIGN: A baseline bladder perforation rate was determined by retrospective chart review. A prospective educational intervention, consisting of a 10-minute instructional video with preoperative simulation using a simple bony pelvis model, was then implemented among residents on the urogynecology service from December 2017 through March 2020. The primary outcome was the change in the bladder perforation rate. Compliance with the intervention protocol was a secondary outcome. Categorical data were evaluated using the χ 2 or Fisher exact test. Continuous variables were assessed using the Student t test or Mann-Whitney U test as appropriate. RESULTS: Two hundred fifteen retropubic midurethral sling cases were included in analysis. There were no significant demographic differences between the patients undergoing surgery preintervention and postintervention. Resident surgeons were in their second (47.4%) and third (52.6%) years of training. The postintervention bladder perforation rate was 6.5%, which is a 35% reduction from the preintervention perforation rate of 10% ( P = 0.19). The instructional video and preoperative simulation were successfully implemented in 193 of 215 (89.8%) eligible cases. CONCLUSION: Despite high compliance, the combination of the instructional video and preoperative low-fidelity bony pelvis simulation was not effective in reducing tension-free vaginal tape-associated bladder perforations among residents.

Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension.

IMPORTANCE: The impact of a persistently enlarged genital hiatus (GH) after vaginal hysterectomy with uterosacral ligament suspension on prolapse outcomes is currently unclear. OBJECTIVES: This secondary analysis of the Study of Uterine Prolapse Procedures Randomized trial was conducted among participants who underwent vaginal hysterectomy with uterosacral ligament suspension. We hypothesized that women with a persistently enlarged GH size would have a higher proportion of prolapse recurrence. STUDY DESIGN: Women who underwent vaginal hysterectomy with uterosacral ligament suspension as part of the Study of Uterine Prolapse Procedures Randomized trial (NCT01802281) were divided into 3 groups based on change in their preoperative to 4- to 6-week postoperative GH measurements: (1) persistently enlarged GH, 2) improved GH, or (3) stably normal GH. Baseline characteristics and 2-year surgical outcomes were compared across groups. A logistic regression model for composite surgical failure controlling for advanced anterior wall prolapse and GH group was fitted. RESULTS: This secondary analysis included 81 women. The proportion with composite surgical failure was significantly higher among those with a persistently enlarged GH (50%) compared with a stably normal GH (12%) with an unadjusted risk difference of 38% (95% confidence interval, 4%-68%). When adjusted for advanced prolapse in the anterior compartment at baseline, the odds of composite surgical failure was 6 times higher in the persistently enlarged GH group compared with the stably normal group (95% confidence interval, 1.0-37.5; P = 0.06). CONCLUSION: A persistently enlarged GH after vaginal hysterectomy with uterosacral ligament suspension for pelvic organ prolapse may be a risk factor for recurrent prolapse.

Induction of Cellular Senescence in Rat Vaginal Fibroblasts and Treatment With Senolytics: An in Vitro Model for the Study of Pelvic Organ Prolapse.

OBJECTIVE: The objective of this study was to develop an in vitro model of cellular senescence using rat vaginal fibroblasts and determine the effects of treatment with senolytics. METHODS: Rat vaginal tissue biopsies were collected. Primary vaginal fibroblasts were isolated and characterized by immunofluorescence. To induce cellular senescence, fibroblasts were treated with etoposide at 3, 10, and 20 mM for 24 hours, followed by treatment with the senolytics dasatinib (1 mM) and/or quercetin (20 mM). After treatment, RNA was extracted and the expression of selected genes was quantified. Immunostaining of senescence markers was also performed. RESULTS: Fibroblasts were confirmed by positive immunostaining for α-smooth muscle actin and vimentin, and negative immunostaining for pan-cytokeratin. Treatment with etoposide resulted in a dose-dependent increase in expression of the senescence-associated secretory phenotype markers MMP-7, MMP-9, and IL-b1 (P < 0.05) compared with controls. Immunostaining showed increased expression of γ-H2A and p21 after treatment with etoposide. Cells treated with dasatinib and quercetin after etoposide treatment had decreased expression of p21, MMP-7, MMP-9, and IL-1b compared with cells treated only with etoposide (P < 0.05). CONCLUSIONS: Upregulation of senescence-associated factors provided evidence that senescence can be induced in vaginal fibroblasts in vitro. Furthermore, treatment with the senolytics dasatinib and quercetin abrogated the senescence phenotype induced by etoposide in rat vaginal fibroblasts. Our findings provide a novel model for the study and development of new therapies targeting the disordered extracellular matrix associated with pelvic organ prolapse.

Impact of vaginal distention on cell senescence in an animal model of pelvic organ prolapse.

OBJECTIVE: Cellular senescence, associated with aging, leads to impaired tissue regeneration. We hypothesize that vaginal injury initiates cell senescence, further propagated during aging resulting in pelvic organ prolapse (POP). Our objective was to employ a mouse model of POP (Fibulin-5 knockout mice, Fbln5-/-) to determine if vaginal distention leads to cellular senescence and POP. METHODS: 6wk old females [wild-type (WT), n = 81; Fbln5-/-, n = 47)] were assigned to control vs vaginal distention, which approximated vaginal delivery. Serial POP measurements were obtained until vagina were harvested from euthanized mice at 24, 48, 72 h and 1wk. Markers of cell senescence were quantified by immunofluorescence. DNA damage was assessed with γ-H2Ax. RESULTS: WT distended mice showed decreased p53 (p = 0.0230) and γ-H2Ax (p = 0.0008) in vaginal stromal cells at 1wk compared to controls. In WT mice, SA-ß-Gal activity increased 1wk after distention (p = 0.05). In Fbln5-/- mice, p53 and γ-H2Ax did not decrease, but p16 decreased 72 h after distention (p = 0.0150). SA-ß-Gal activity also increased in Fbln5-/-, but at earlier time points and 1wk after distention (p < 0.0001). Fbln5-/- mice developed POP after distention earlier than non distended animals (p = 0.0135). CONCLUSIONS: Vaginal distention downregulates p53 and γ-H2Ax in WT mice, thereby promoting cell proliferation 1wk after injury. This was absent among Fbln5-/- distention mice suggesting they do not escape senescence. These findings indicate a failure of cellular protection from senescence in animals predisposed to POP.

Comparisons of Functional Apical Support After Sacral Hysteropexy Versus Sacral Colpopexy: A Cadaveric Study.

OBJECTIVES: Prolapse procedures with uterine preservation offer an alternative to colpopexy with hysterectomy. Few studies have examined the differences in anatomic or subjective outcomes following sacral hysteropexy versus sacral colpopexy with hysterectomy. This study sought to compare the ability of sacral hysteropexy and sacral colpopexy with hysterectomy to resist downward traction as an estimate of apical support in human cadavers. METHODS: Sacral hysteropexy was performed on unembalmed female cadavers. A metal bolt/washer was threaded through the uterine fundus, down the cervical canal. and out the vagina and fastened to a waxed surgical filament, which ran over a fixed pulley at the table's end. Successive weights were added to provide increasing loads on the uterine fundus, and the distances traversed by the fundus were recorded. The same process was repeated after completion of a total hysterectomy (with vaginal cuff closure) and subsequent sacral colpopexy in the same specimen. Data were analyzed using paired-sample t test and repeated-measures analysis of variance (Sigma Plot version 13.0), with P ≤ 0.05 considered statistically significant. RESULTS: Eight female cadavers were utilized. With the addition of each weight, the average distance traversed by the uterine fundus or vaginal cuff gradually increased. There were no statistical differences in the distances moved by the apex between sacral hysteropexy and total hysterectomy/sacral colpopexy. CONCLUSIONS: These results suggest that functional support provided by sacral hysteropexy and sacral colpopexy with hysterectomy may be similar. Further studies are needed to correlate these findings with patient satisfaction, which may vary despite similar anatomic results.

Does Living With Human Immunodeficiency Virus Increase Pelvic Reconstructive Surgery Perioperative Complication Risk? A Multicenter Retrospective Cohort Study.

OBJECTIVE: To determine if women with human immunodeficiency virus (HIV) undergoing pelvic reconstructive surgery (PRS) have an increased risk of perioperative and postoperative complications compared with HIV-negative controls. STUDY DESIGN: Multicenter, retrospective matched cohort study of patients with and without HIV infection who underwent PRS between 2006 and 2016. Cases were identified using International Classification of Disease, 9th edition Clinical Modification and 10th edition Clinical Modification and current procedural terminology (CPT) codes encompassing HIV diagnoses and pelvic reconstructive surgeries. Controls were identified as patients without HIV who underwent similar procedures, performed by the same surgeon during the same 1-year period as surgeries performed on patients with HIV. Cases were matched to controls at a ratio of 1:3. The primary outcome was composite complication rate within 1 year of surgery. RESULTS: Sixty-three patients with HIV and 187 controls were identified. There was no difference in the composite complication rate between women with HIV and HIV-negative women (36.5% vs 30.0%, P = 0.15) over 1 year. However, 19.1% of patients with HIV compared with 5.4% controls had Clavien Dindo Grade I complications (P = 0.002), and 11.1% of HIV patients had urinary retention within 6 weeks of surgery compared with 3.2% of controls (P = 0.02). After multivariable logistic regression used to adjust for confounders, living with HIV was not associated with an increased risk of complications. CONCLUSIONS: Patients living with HIV are not at an increased risk of complications within 1 year of PRS compared with patients without HIV.

Rectal prolapse and urinary retention: A case report of an "anal cystocele".

BACKGROUND: Concomitant rectal and vaginal prolapse is diagnosed in 14-55% of patients who present for pelvic floor evaluation.Case: A patient was referred for pelvic floor evaluation in the setting of rectal prolapse and urinary retention. Preoperative magnetic resonance (MR) imaging revealed the presence of a posterior cystocele prolapsing through the full-thickness rectal prolapse. CONCLUSION: Rectal prolapse with concomitant urinary retention should raise suspicion for posterior bladder prolapse. Here we propose the new term "anal cystocele". MR imaging aids in the diagnosis and treatment planning for this condition.

Sacrocolpopexy With Concomitant Total vs Supracervical Hysterectomy: Functional Support Comparisons in Cadavers.

OBJECTIVE: This study aimed to compare the ability of abdominal sacrocolpopexy (ASC) with concomitant total vs supracervical hysterectomy to resist downward traction as a measure of functional anatomic support in human cadavers. METHODS: Supracervical hysterectomy was performed on unembalmed cadaver specimens, followed by ASC attaching polypropylene mesh to the posterior cervix/vagina only and then the anterior and posterior cervix/vagina. Using a metal bolt placed through the cervix tied to a filament passing through a fixed pulley system, successive weights of 0.5 to 3.0 kg were added to provide increasing loads on the apex (cervix), and the distances traversed by the apex were recorded. The same process was then repeated in each specimen after removal of the cervix (with vaginal cuff closure). One-way and repeated-measures analysis of measure was used for between-group and within-group comparisons, respectively, with P ≤ 0.05 considered statistically significant. RESULTS: Eight cadavers were examined. At lower weight loads, pulling distances in the 4 groups examined were similar and were not significantly different with the presence or absence of the cervix. At weight loads of 2.5 kg or greater, we noted a trend of increased pulling distances when posterior mesh only was used vs when anterior/posterior mesh was placed, although this difference was not significant. Interestingly, there was tearing of the vaginal wall or partial separation of mesh/sutures attachments to the vagina noted in 3 specimens. CONCLUSIONS: This study showed no differences in the ability of the cervix (after supracervical hysterectomy) compared with the vaginal cuff (after total hysterectomy) to resist downward traction of successive weights after ASC. Clinical trials are necessary to correlate these findings with prolapse recurrence rates and patient satisfaction following these procedures.

Vaginal Hysterectomy Suturing Skills Training Model and Curriculum.

BACKGROUND: Declining vaginal hysterectomy numbers in obstetrics and gynecology training programs highlights the need for innovative methods to teach vaginal surgical skills. We describe our experience with a vaginal hysterectomy skills simulation curriculum. INSTRUMENT: A low-fidelity bench model was constructed to simulate four vaginal hysterectomy suturing tasks. A polyvinyl chloride downspout adapter and low-cost materials simulate the Heaney pedicle stitch, simple pedicle stitch, double ligature, and continuous running stitch. EXPERIENCE: Faculty expert vaginal surgeons established proficiency levels for each task. Resident (N=30) pass rates for tasks 1, 2, and 3 were 1 of 30 (3.3%), 7 of 30 (23.3%), and 4 of 30 (13.3%), respectively, for the left side, and 3 of 30 (10%), 9 of 30 (30%), and 10 of 30 (33.3%), respectively, for the right side. For task 4, the pass rate was 14 of 30 (46.7%). The majority of residents felt that the model simulates the technical skills required for vaginal hysterectomy and agreed that vaginal skills laboratory training would improve their ability to perform procedures in the operating room. Ninety-two percent of residents felt that a vaginal surgery skills curriculum would be a useful addition to their simulation education. CONCLUSION: A proficiency-based vaginal hysterectomy skills simulation curriculum using a low-fidelity model may be an important training and evaluation tool for vaginal surgical skills training.