Barbed Versus Nonbarbed Suture for Posterior Colporrhaphy: A Randomized Controlled Trial.

IMPORTANCE: There is limited literature or even consensus on the suture material used for posterior vaginal repairs. OBJECTIVES: This study aimed to compare outcomes of barbed versus nonbarbed delayed absorbable suture used for posterior colporrhaphy. STUDY DESIGN: This study conducted a randomized controlled trial of 72 women undergoing posterior repair using standardized technique-concurrent procedures permitted with barbed (n = 36) or nonbarbed (n = 36) suture. Standardized examinations, validated questionnaires, and a visual analog scale (VAS) were completed at baseline, 6 weeks, and 12 months, and a telephone interview was conducted at 6 months. The primary outcome was posterior compartment pain at 6 weeks, measured by a VAS. RESULTS: Seventy-two women enrolled, with follow-up rates 6 weeks (100%), 6 months (90.3%), and 12 months (73.6%). Demographics were similar between groups. A VAS with movement was not different between groups at 6 weeks. The odds of experiencing vaginal pain, having myofascial pain on examination, or being sexually active postoperatively were not different between the groups. There were no differences in the length of posterior colporrhaphy, surgical times, or hospital length of stay between the groups. Suture passes were lower in the nonbarbed group (median, 4 vs 7; P = <0.001), and suture burden was higher in the nonbarbed group (median, 26.9 vs 10.5 cm; P = <0.001). There was overall improvement in Pelvic Floor Distress Inventory Short Form 20 prolapse and colorectal subscores but no differences between groups. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form 12 scores improved, and dyspareunia decreased at 6 and 12 months in both groups. In addition, there were few anatomic recurrences at 6 weeks (0%) and 12 months (3.4%) and few adverse events. CONCLUSIONS: This study found no differences in primary or secondary outcomes; however, both suture types resulted in clinical improvements in quality-of-life measures and sexual function.

A resident robotic curriculum utilizing self-selection and a web-based feedback tool.

To describe an obstetrics and gynecology residency robotic curriculum, facilitated by a web-based feedback and case-tracking tool, allowing for self-selection into advanced training. Phase I (Basic) was required for all residents and included online training modules, online assessment, and robotic bedside assistant dry lab. Phase II (Advanced) was elective console training. Before live surgery, 10 simulation drills completed to proficiency were required. A web-based tool was used for surgical feedback and case-tracking. Online assessments, drill reports, objective GEARS assessments, subjective feedback, and case-logs were reviewed (7/2018-6/2019). A satisfaction survey was reviewed. Twenty four residents completed Phase I training and 10 completed Phase II. To reach simulation proficiency, residents spent a median of 4.1 h performing required simulation drills (median of 10 (3, 26) attempts per drill) before live surgery. 128 post-surgical feedback entries were completed after performance as bedside assistant (75%, n = 96) and console surgeon (5.5%, n = 7). The most common procedure was hysterectomy 111/193 (58%). Resident console surgeons performed portions of 32 cases with a mean console time of 34.6 ± 19.5 min. Mean GEARS score 20.6 ± 3.7 (n = 28). Mean non-technical feedback results: communication (4.2 ± 0.8, n = 61), workload management (3.9 ± 0.9, n = 54), team skills (4.3 ± 0.8, n = 60). Residents completing > 50% of case assessed as "apprentice" 38.5% or "competent" 23% (n = 13). After curriculum change, 100% of surveyed attendings considered residents prepared for live surgical training, vs 17% (n = 6) prior to curriculum change [survey response rate 27/44 (61%)]. Attendings and residents were satisfied with curriculum; 95% and recommended continued use 90% (n = 19).This two-phase robotic curriculum allows residents to self-select into advanced training, alleviating many challenges of graduated robotic training.

Recurrent Paravaginal Abscess: An Unusual Presentation of a Distal Ectopic Ureteral Remnant.

Introduction: Obstructed hemivagina ipsilateral renal agenesis (OHVIRA) is a rare syndrome with limited data on both treatment and postoperative sequelae, specifically of ectopic ureters to the vagina. Case Description: This case study describes a 22-year-old patient with OHVIRA syndrome presenting with pelvic pain and drainage from a chronic vaginal abscess secondary to a remnant distal ectopic ureter after nephrectomy and proximal ureterectomy. Imaging was significant for a right paravaginal abscess. Previously, the patient was treated with conservative therapy and on presentation her evaluation confirmed a right paravaginal abscess. She subsequently underwent a robot-assisted incision and drainage of the paravaginal abscess and excision of the remnant distal ectopic ureter. She did well postoperatively without recurrence. Discussion: We discuss the successful surgical technique used to identify and excise a paravaginal abscess. We also highlight the unique anatomy of a patient with OHVIRA syndrome. Lastly, we underline the importance of a complete resection of an ectopic ureter to the vagina at the time of nephrectomy, given the potential risk of ascending chronic infection and recurrent abscess formation.

Post-ablation tubal sterilization syndrome: Does route of sterilization matter?

OBJECTIVE: To compare the prevalence of clinical post-ablation tubal sterilization syndrome among women who underwent abdominal (i.e., peripartum or laparoscopic) vs hysteroscopic permanent contraception in addition to endometrial ablation. STUDY DESIGN: This study was a retrospective cohort study conducted at an academic medical center. We included women (N = 188) who successfully underwent both endometrial ablation and permanent contraception between 2005 and 2017. Forty-one women underwent hysteroscopic permanent contraception and 147 underwent abdominal (i.e., peripartum or laparoscopic) permanent contraception. The primary outcome was the prevalence of clinical post-ablation tubal sterilization syndrome, as defined by new or worsening cyclic pelvic pain after completion of both procedures. RESULTS: The overall prevalence of the syndrome was 19.1% (34 of 178 women who followed up), with no detected difference between those who underwent hysteroscopic (6 of 38, 15.8%) vs abdominal permanent contraception (28 of 140, 20.0%, p = 0.55). In multivariate regression modeling, when adjusted for race, parity, gynecologic pathologies, hormonal medication use, and the presence of baseline pain (both pelvic and non-pelvic) only younger patient age was marginally associated with increased odds of the syndrome (aOR 1.85, 95% CI 1.01- 3.45, p = 0.05), while abdominal as compared to hysteroscopic permanent contraception was not (aOR 1.29, 95% CI 0.59-2.84, p = 0.53). Of the 28 patients with clinical post-ablation tubal sterilization syndrome who underwent hysterectomy and/or salpingectomy as treatment for their pain, none showed signs of hematosalpinx or hematometra at the time of surgery or on final pathology. CONCLUSION: We did not find evidence that route of permanent contraception affects the risk of post-ablation tubal sterilization syndrome development. Younger patients may be at higher risk of this syndrome.

Biologic Grafts for Use in Pelvic Organ Prolapse Surgery: a Contemporary Review.

PURPOSE OF REVIEW: Pelvic organ prolapse (POP) is a common condition and there is a plethora of surgical techniques available to address this problem. We present a review of biologic grafts, including the latest literature to help guide a surgeon's choice on the type of biologic materials to augment repairs. RECENT FINDINGS: Since the 2019 Food and Drug Administration (FDA) ban on mesh, including xenograft, there is a sparsity of biologic graft products available for POP repairs. This has led to a significant decrease in surgical application. Surgeons must be familiar with the biochemical properties, processing, and clinical application of biologic grafts prior to use. They should also be familiar with alternative operative techniques that utilize autografts, although there is limited outcome data on these techniques. With heightened awareness of mesh and its complications, biologic grafts have made a resurgence. Surgeons must be well versed on their available options. Current literature is limited, and studies have not demonstrated superiority of biologic graft over native tissue repairs for prolapse. Nevertheless, there is a role for these types of biologic graft material in specific patient populations. Future studies are warranted.

Adjuvant administration of 17-α-hydroxy-progesterone caproate in women with three or more second trimester pregnancy losses undergoing cervical cerclage is no more effective than cerclage alone.

OBJECTIVE: To investigate the role of adjuvant 17-α-hydroxy-progesterone caproate (17OHP-C) in reducing the risk of preterm delivery <34 weeks and adverse perinatal outcomes in women with ≥3 second trimester pregnancy losses attributed to cervical insufficiency undergoing prophylactic cerclage. MATERIAL AND METHODS: Retrospective cohort study of women with prophylactic cerclage placed between 2006 and 2014 divided into a cohort of (i) those receiving adjuvant 17OHP-C (n=43), and (ii) controls with cerclage alone (n=59). RESULTS: Demographic characteristics were comparable in both groups. There was no significant difference in gestational age at delivery between the cerclage-17OHP-C group (33.4±5.6 weeks) and the cerclage-alone group (34.4±4.6 weeks); P=0.33. We noted a non-significant increase for deliveries <34 weeks in the cerclage-17OHP-C group (44.2%) compared to controls (28.8%) which remained non-significant after adjusting for confounders; P=0.46. There was no statistically significant difference in the rate of delivery <37, 32, 28 and 24 weeks. Adverse neonatal outcomes were comparable in both groups (cerclage-17OHP-C 48.8% vs. cerclage-alone 39%); P=0.43. CONCLUSION: Intramuscular 17OHP-C in combination with prophylactic cerclage in women with cervical insufficiency and ≥3 second trimester pregnancy losses had no synergistic effect in reducing the rate of recurrent preterm birth or improving perinatal outcomes.