Defining success after surgical treatment of stress urinary incontinence.

BACKGROUND: A consensus standardized definition of success after stress urinary incontinence surgical treatment is lacking, which precludes comparisons between studies and affects patient counseling. OBJECTIVE: This study aimed to identify optimal patient-centric definition(s) of success after stress urinary incontinence surgical treatment and to compare the identified "more accurate" treatment success definitions with a commonly used composite definition of success (ie, no reported urine leakage, negative cough stress test result, and no retreatment). STUDY DESIGN: We evaluated 51 distinct treatment success definitions for participants enrolled in a previously conducted randomized trial of stress urinary incontinence treatments concomitantly performed with sacrocolpopexy (NCT00934999). For each treatment success definition, we calculated the mean (SD) of participant-assessed symptom improvement and participant-assessed surgical success scores with an 11-point Likert scale among those achieving success and failure. The "more accurate" treatment success definition(s) were identified by measuring the magnitude of the mean difference of participant assessments with Hedges g values. The treatment success definitions with the highest Hedges g values were considered "more accurate" treatment success definitions and were then compared with the composite definition of success. RESULTS: The percentage of participants who had treatment success (6.4% to 97.3%) and Hedges g values (-4.85 to 1.25) varied greatly according to each treatment success definition. An International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score ≤5, Urogenital Distress Inventory-6 score ≤33.3, and a no/mild stress urinary incontinence response on Urogenital Distress Inventory-6 question 3 had the highest Hedges g values and were considered the top 3 "more accurate" treatment success definitions. Paradoxically, treatment success definitions that required a negative cough stress test result or no persistent urinary leakage greatly reduced the ability to differentiate between participant-assessed symptom improvement and surgical success. When the "more accurate" treatment success definitions were compared with the composite definition, patients with failed treatment according to the composite definition had lower Urinary Impact Questionnaire-7 scores and a higher proportion of survey responses indicating complete satisfaction or some level of satisfaction and very good/perfect bladder condition. In addition, the composite definition had considerably fewer favorable outcomes for participants than did the top 3 "more accurate" treatment success definitions. CONCLUSION: Successful outcomes of stress urinary incontinence surgical treatments for women undergoing concurrent sacrocolpopexy varied greatly depending on the definition used. However, stringent definitions (requiring complete dryness) and objective testing (negative cough stress test result) had decreased, rather than increased, participant-assessed symptom improvement and surgical success scores. The "more accurate" treatment success definitions better differentiated between participant-assessed symptom improvement and surgical success than the composite definition. The composite definition disproportionately misidentified participants who reported minor symptoms or complete/partial satisfaction with their outcome as having treatment failures and yielded a considerably lower proportion of women who reported favorable outcomes than did the top 3 "more accurate" treatment success definitions.

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice.

BACKGROUND: Current evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers. OBJECTIVE: To determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic, or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload. STUDY DESIGN: The bundle of opioid-sparing strategies and tiered prescribing protocol intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month postintervention (bundle of opioid-sparing strategies and tiered prescribing protocol) cohort to 6-month preintervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month washout period was observed after bundle of opioid-sparing strategies and tiered prescribing protocol initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents prescribed. Pain control was measured by pain scores, postdischarge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and postdischarge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the bundle of opioid-sparing strategies and tiered prescribing protocol protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables. RESULTS: Four hundred sixteen patients were included in the primary analysis (207 bundle of opioid-sparing strategies and tiered prescribing protocol, 209 usual care). Baseline demographics were similar between groups, except a lower proportion of irritable bowel syndrome (13% vs 23%; P<.01) and pelvic pain (15% vs 24.9%; P=.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; P=.02) in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was more likely to be discharged without opioids (68.1% vs 10.0%; P<.01). In those prescribed opioids, total oral morphine equivalents on discharge was significantly lower in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort (48.1 vs 81.8; P<.01). The bundle of opioid-sparing strategies and tiered prescribing protocol cohort had a 20.6 greater odds (confidence interval 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to nonsteroidal anti-inflammatory drugs. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; P=.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; P=.77), emergency room visits for pain (3.4% vs 2.9%; P=.76), postoperative pain scores (mean 4.7 vs 4.0; P=.07), or patient satisfaction with pain control (81.5% vs 85.6%; P=.21). After bundle of opioid-sparing strategies and tiered prescribing protocol implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; P=.02). Similar results were identified when nonadherent prescribing was included in the analysis. CONCLUSION: A bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

McIndoe neovagina creation for the management of vaginal agenesis.

This video reviews technical considerations for performing a modified McIndoe vaginoplasty with skin graft. A 24-year-old female was referred for management of vaginal agenesis. She had unsuccessfully tried vaginal dilation and was interested in vaginal canal creation. A 10 × 20-cm split-thickness skin graft was harvested from the buttock and secured to a condom-covered rubber-sponge mold. The vaginal dissection was initially performed with electrocautery and sharp dissection to enter the plane between the bladder anteriorly and the rectum posteriorly. Then, blunt dissection using a finger, surgical sponges, and retractors was performed to open the space to the level of the peritoneal reflection. With the dissection completed, the graft-covered mold was inserted and secured with labial stay sutures. During the second stage of the procedure, roughly 14 days later, the mold was removed, the graft assessed, and the distal edges secured. A polyethylene mold was then used as the wound continued to heal. The patient had an uncomplicated perioperative course. She had excellent take of her skin graft, with 10 cm vaginal length and adequate vaginal caliber. Vaginoplasty with a split-thickness skin graft is an excellent surgical option for vaginal canal creation in patients with vaginal agenesis.

Surgical management of stress urinary incontinence following traumatic pelvic injury.

INTRODUCTION AND HYPOTHESIS: The objective was to discuss the evaluation and management of stress urinary incontinence (SUI) following traumatic pelvic injury by use of a video case. METHODS: We present a patient with severe SUI following pelvic trauma and our surgical approach to her case. Her injuries included two sacral compression fractures and four un-united bilateral pubic rami fractures, with her right-upper pubic rami impinging on the bladder. RESULTS: Preoperative assessment included detailed review of her pelvic imaging, multichannel urodynamic testing, cystoscopy, and examination of periurethral and bony pelvis anatomy. We proceeded with a synthetic retropubic mid-urethral sling, which required medial deviation of the trocar passage owing to her distorted anatomy. Rigid cystoscopy provided an inadequate bladder survey following sling placement, thus flexible cystoscopy was used to confirm the absence of bladder perforation. Postoperatively, our patient experienced resolution of SUI. CONCLUSIONS: In patients who sustain pelvic fractures, imaging to evaluate bony trauma and genitourinary tract injury is essential. Urodynamic testing provides clarity of the nature and severity of incontinence symptoms. Rigid and/or flexible cystoscopy should be performed for diagnostic purposes pre-operatively and after operative intervention. Typical anti-incontinence procedures can be offered to these patients, but since bony anatomy can be unreliable, an individualized approach to their specific injury should be utilized.

Martius labial fat pad graft (use in rectovaginal fistula repair).

INTRODUCTION AND HYPOTHESIS: The objective is to demonstrate the utility of the Martius labial fat pad graft in pelvic fistula repair. METHODS: An incision is made over the labium majus from the level of the clitoral hood superiorly and extending inferiorly to the level of the labiocrural fold. The fibrofatty graft is then mobilized from the adjacent labium majus. The flap can be divided either at its anterior or at its posterior pedicle. A subepithelial defect is created through which the flap will be passed. The flap is sewn into place by attaching it to the underlying rectovaginal fascia without associated tensioning. Next, the posterior vaginal wall is closed over the graft with a series of everting subepithelial mattress sutures followed by a reinforcing layer of interrupted #1 Vicryl through the vaginal epithelium. CONCLUSIONS: The advantages of the Martius flap in fistula repair include low morbidity, lack of a cosmetic defect, and the need for only a single surgical field. Its prominent fibrous component makes it a stronger graft than adipose tissue from other areas and its abundant blood supply promotes rapid neovascularization and lends itself well to many surgical modifications that can be utilized in even the most difficult of fistula repairs.

Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery.

BACKGROUND: Nationally, there is increasing concern regarding the volume of opioid medications prescribed postoperatively and the rate of prescription opioid-related adverse events. In evaluation of this, several reports have identified significant variability in postoperative opioid-prescribing patterns, including quantities exceeding patient's needs, especially after minor surgical procedures. However, data regarding patient's postoperative opioids needs following surgery for pelvic organ prolapse are sparse. OBJECTIVE: To design procedure-specific opioid-prescribing recommendations for pelvic organ prolapse surgeries and evaluate their impact on opioid stewardship. STUDY DESIGN: We prospectively evaluated opioid-prescribing patterns, patient use, medication refills, and patient satisfaction in women undergoing prolapse surgery (ie, vaginal, abdominal, or robotic) during an 8-month time period. Two cohorts of women, stratified by whether they had surgery before or after implementation of procedure-specific opioid-prescribing recommendations, were evaluated. Postoperative opioid usage (assessed via pill count), medication refills, and satisfaction with pain management after hospital dismissal were evaluated by telephone call 2 weeks after surgery. Postoperative opioid prescribing and use were recorded after conversion to oral morphine equivalents. RESULTS: Overall, 96 women were included, 57 in the initial baseline cohort, and 39 following implementation of the prescribing recommendations. In the initial cohort, 32.8% of the prescribed oral morphine equivalents (3607/11,007 mg) were consumed. Following implementation of the prescribing recommendations, median oral morphine equivalents prescribed decreased from 200 mg oral morphine equivalents (interquartile range 150, 225) to 112.5 mg oral morphine equivalents (interquartile range 22.5, 112.5; P<.0001). The total oral morphine equivalents prescribed decreased by 45% when compared with the volume that would have been prescribed before implementing the recommendations. The amount of leftover opioids per patient significantly decreased as well (P<.0001). Pain medication refills increased after the intervention (18% vs 3.5%; P=.03), whereas satisfaction scores were similar in both cohorts (P=.87). CONCLUSIONS: By using procedure-specific opioid prescribing recommendations, we decreased the number of opioids prescribed at hospital dismissal by roughly one half. Decreased opioid prescribing did not adversely impact patient satisfaction.

Sitting versus standing makes a difference in musculoskeletal discomfort and postural load for surgeons performing vaginal surgery.

INTRODUCTION AND HYPOTHESIS: We compared musculoskeletal discomfort and postural load among surgeons in sitting and standing positions during vaginal surgery. MATERIALS AND METHODS: Assessment of discomfort and posture of the primary surgeons in both positions was performed at two institutions. The primary outcome was an increase in body discomfort score after surgery as determined from subjective responses using validated tools. The secondary outcome was the percentage of time spent in awkward body postures measured objectively and stratified into awkward postures for neck, trunk, and bilateral shoulder angles. Variables were compared between sitting and standing positions using Fisher's exact test for primary outcomes and Wilcoxon rank-sum test for secondary outcomes. RESULTS: Data were collected for 24 surgeries from four surgeons in sitting position and nine surgeries from nine surgeons in standing position. The standing surgeons reported a significant increase in discomfort postoperatively for bilateral wrists, thighs, and lower legs compared with the sitting surgeons. The median percentage of time spent in awkward postures was significantly lower for the trunk in the standing versus sitting position (median 0.3% vs 58.8%, p < 0.001) but was significantly higher for both shoulders in the standing versus the sitting position (right shoulder: median 17.8% vs 0.3%, p = 0.003; left shoulder: median 7.4% vs 0.2%, p = 0.003). CONCLUSION: Surgeons reported more discomfort in when performing vaginal surgery while standing. The postural load was worse for trunk but favorable for bilateral shoulders when seated. Such differences may impact a surgeon's decision to perform vaginal surgery seated rather than standing.

Randomized controlled trial of silver-alloy-impregnated suprapubic catheters versus standard suprapubic catheters in assessing urinary tract infection rates in urogynecology patients.

INTRODUCTION AND HYPOTHESIS: Catheter-associated urinary tract infections (UTI) are the most common health-care-related infections. We aimed to compare the UTI rate among women undergoing urogynecological procedures with a silver-alloy suprapubic catheter (SPC) and a standard SPC, and identify the risk factors predisposing patients to UTI. METHODS: Patients who were to undergo placement of an SPC as part of pelvic organ prolapse surgery were enrolled between 1 August 2011 and 30 August 2017, and randomized to either standard SPC or silver-alloy SPC. Follow-up was performed at a postoperative visit or via a phone call at 6 weeks. The primary outcome was UTI. RESULTS: Of the 288 patients who were randomized, 127 with standard SPC and 137 with silver-alloy SPC were included in the analysis. Twenty-nine out of 123 women with standard SPC (23.6%) and 24 out of 131 (18.3%) with silver-alloy SPC were diagnosed with UTI within 6 weeks postoperatively (p = 0.30). In univariate analysis, non-white race (odds ratio [OR] 5.36, 95% CI 1.16-24.73) and diabetes (OR 2.80, 95% CI 1.26-6.23) were associated with increased risk of UTI. On multivariate analysis, only diabetes remained an independent risk factor. Comparisons between groups were evaluated using two-sample t test for age, Chi-squared tests for diabetes, and Wilcoxon rank sum test for all other variables. CONCLUSION: There was only a 5% difference in 6-week UTI rates between those who received standard vs silver-alloy SPC; the study was not powered to detect such a small difference. Diabetes was identified as a risk factor for SPC-associated UTI in women undergoing pelvic reconstructive surgeries.

Entry into the anterior cul-de-sac during vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vaginal hysterectomy, including tips for troubleshooting difficult cases such as: uterine procidentia, cervical elongation, and multiple prior cesarean sections. METHODS: Anterior cul-de-sac entry is a critical step in performing a vaginal hysterectomy. In this video, we review our approach to anterior entry in patients with normal anatomy, followed by a discussion of techniques that may be useful in cases with challenging anatomy. To start, we drain the bladder, set up exposure with Deaver retractors, and make a circumferential incision at the cervicovaginal junction. In cases with normal anatomy, using sharp, followed by broad blunt finger dissection, the vesicocervical space is opened, and the peritoneal reflection is identified and sharply entered. If this is not possible, additional techniques such cystoscopic bladder illumination, posterior entry first, securing pedicles with extraperitoneal ties, or additional sharp dissection may be utilized. With all techniques, proper intraperitoneal entry should be verified by the visualization of small bowel or fat. CONCLUSION: This video reviews technical considerations for anterior cul-de-sac entry during vaginal hysterectomy in patients with normal anatomy and provides tips for troubleshooting challenging cases.

Long-term outcomes and predictors of failure after surgery for stage IV apical pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of prolapse recurrence. METHODS: The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan-Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence. RESULTS: Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p < 0.001) and less likely to have a prior hysterectomy (39.7 vs 86.4%; p < 0.001) or prior apical prolapse repair (8.2 38.6%; p < 0.001). Median follow-up was 4.3 years [interquartile range (IQR) 1.1-7.7]. Survival free of recurrence was similar between USLS and sacrocolpopexy (p = 0.43), with 5-year rates of 88.7 and 97.6%, respectively. Younger age [adjusted hazard ratio (aHR) 1.55, 95% confidence interval (CI) 1.12-2.13; p = 0.008] and prior hysterectomy (aHR 2.8, 95% CI 1.39-5.64; p = 0.004) were associated with the risk of prolapse recurrence, whereas type of surgery approached statistical significance (aHR 2.76, 95% CI 0.80-9.60; p = 0.11). CONCLUSIONS: Younger age and history of prior hysterectomy were associated with an increased risk of recurrent prolapse symptoms. Notably, excellent survival free of prolapse recurrence were obtained with both surgical techniques.

Vaginal versus Robotic Hysterectomy for Commonly Cited Relative Contraindications to Vaginal Hysterectomy.

STUDY OBJECTIVE: To compare outcomes of vaginal hysterectomy (VH) and robotic-assisted hysterectomy (RH) among women with conditions perceived as contraindications to VH (uterine size ≥ 12 weeks' gestation, no vaginal parity, prior cesarean delivery, and obesity). DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: Tertiary US medical center. PATIENTS: Women with VH or RH. Women with conditions perceived as contraindications affecting surgical choice were excluded. INTERVENTIONS: VH or RH for benign uterine disease at our institution during 2009 through 2013. MEASUREMENTS AND MAIN RESULTS: Among women with the perceived contraindications, a logistic regression model was fit to compare each binary outcome between VH and RH. Models were weighted using inverse probability of treatment weights derived from propensity scores to adjust for covariate imbalance between procedures. The cohort had 692 VHs and 472 RHs. Among 160 women with uterine size ≥ 12 weeks' gestation, RH patients were less likely to have uterine debulking (adjusted odds ratio [aOR], .37; 95% confidence interval [CI], .15-.95]) than VH patients and more likely to have accordion grade ≥ 2 postoperative complications (aOR, 7.20; 95% CI, 1.46-35.42) and readmission (aOR, 15.55; 95% CI. .85-285.20). Among 272 women with prior cesarean section, RH patients were more likely to have grade ≥ 2 postoperative complications (aOR, 2.85; 95% CI, 1.29-6.30). No outcomes were significantly different between surgical routes among women with no vaginal parity or obesity. Mean operative time was significantly longer for RH. CONCLUSION: VH is a surgical option for patients with the conditions perceived as contraindications for vaginal surgery evaluated herein.

Clinical Manifestations and Outcomes in Surgically Managed Gartner Duct Cysts.

STUDY OBJECTIVE: Gartner duct cysts (GDCs) are rare embryological remnants of the mesonephric duct with the majority of cases discovered incidentally in asymptomatic patients. The largest prior published series evaluating the surgical management of GDCs included 4 patients. The present study aimed to determine the manifestations and outcomes of surgically managed patients with GDCs with important implications for surveillance, monitoring, and management. DESIGN: A retrospective chart review (Canadian Task Force classification III). SETTING: A tertiary care center. PATIENTS: All women diagnosed with GDCs from January 1994 to April 2014 at our institution were identified. Patients were included if they underwent surgical management and had GDCs confirmed by pathology. One hundred twenty-four charts were manually reviewed, and 29 patients were included in the analysis. INTERVENTIONS: All patients underwent surgical management, which included vaginal excision or marsupialization. MEASUREMENTS AND MAIN RESULTS: A total of 29 patients met the inclusion criteria for this study. The median age of the patients included in the analysis was 36 years old. Eleven patients were asymptomatic at the time of diagnosis (37.9%). The reason for surgical intervention was not available in 9 of these patients. Surgical intervention was performed in 2 of the 11 asymptomatic patients because of an increasing size of the lesion during observation. Presenting symptoms included dyspareunia or pain with tampon placement (37.9%), pelvic pain or pressure (24.1%), pelvic mass or bulge (17.2%), and urinary incontinence (6.9%). Preoperative imaging studies were obtained in 62% of patients; ultrasound was used in 44.4%, computed tomographic scanning in 22.2%, magnetic resonance imaging in 16.7%, and multiple modalities in 16.7%. Approximately 10% were found to have other genitourinary anomalies, including a bladder cyst, urethral diverticulum, and a solitary right kidney with uterine didelphis and septate vagina. The average cyst size was 3.5 cm (±1.8 cm). Surgical excision of GDCs was performed in all except for 3 cases of marsupialization. No intraoperative complications occurred. The median follow-up was 82 months (range, 0-246 months). One patient had possible recurrence with dyspareunia and protruding tissue diagnosed 14 months postoperatively. There were no other postoperative complications in the follow-up period. CONCLUSION: GDCs are rare pelvic masses that are often asymptomatic but may present with dyspareunia, pelvic pain or pressure, pelvic mass or bulge, or urinary symptoms. Excision or marsupialization is successful in the majority of cases without significant morbidity.

Effect of chair types on work-related musculoskeletal discomfort during vaginal surgery.

BACKGROUND: Evidence supports that surgeons are at high risk for work-related musculoskeletal disorders. OBJECTIVE: The objective of the study was to compare the effect of different chairs on work-related musculoskeletal discomfort for surgeons during vaginal operations. STUDY DESIGN: This crossover study randomly assigned 4 surgeons to 4 chair types using a 4 × 4 Latin square model: a conventional round stool, a round stool with a backrest, a saddle chair with a backrest, and a Capisco chair. Subjective assessments of surgeon discomfort were performed with a validated body discomfort survey, and workload was assessed with the surgical task load index. The objective postural load was quantified with inertial measurement units of the modified rapid upper limb assessment limits. Subjective and objective assessments of chair comfort were performed with an 11 point scale and seat interface pressure-mapped distributions, respectively. The primary outcome was the difference in body discomfort scores between pre- and postsurgery measurements. Secondary outcomes were the differences in chair comfort scores, postural load, and seating interface pressure-mapped distribution. For each outcome, comparisons among the chair types were based on fitting a linear mixed model that handled the surgeon as a random effect and the chair type as a fixed effect. RESULTS: Data were collected for 48 vaginal procedures performed for pelvic organ prolapse. Mean (SD) duration of surgery was 122.3 (25.1) minutes. Surgeons reported body discomfort during 31 procedures (67.4%). Subjective increase in discomfort from the preoperative state was noted most commonly in the lower back (n = 14, 30.4%), followed by right shoulder (n = 12, 26.1%), upper back (n = 8, 17.4%), hips and buttocks (n = 7, 15.2%), left shoulder (n = 6, 13.0%), right or left thigh (n = 6, 13.0%), and neck (n = 6, 13.0%). Pre- and postsurgery body discomfort scores did not differ with respect to chair type. Chair discomfort scores for the round stool and the saddle chair were significantly higher than the round stool with backrest and the Capisco chair (P < .001). Although the average modified rapid upper limb assessment postural scores showed moderate to high musculoskeletal risk of neck and shoulder discomfort across the 4 surgeons; chair type did not affect postural scores. The saddle chair had significantly reduced dispersion of seated pressure vs the round stool with backrest (P ≤ .001), depicted by the number of cells with pressure values >5 mm Hg. An increased dispersion of pressure across the chair surface was associated with increased comfort (Spearman correlation, 0.40, P = .006). CONCLUSION: Musculoskeletal strain and associated discomfort for surgeons are very high during vaginal operations. Chair type can affect comfort, and chairs with more uniform distribution and fewer pressure points are more comfortable. However, the chair type used in surgery did not influence the musculoskeletal postural load findings.

Total colpocleisis: technical considerations.

INTRODUCTION: We present a video describing the technical considerations for performing a total colpocleisis in the management of symptomatic post-hysterectomy pelvic organ prolapse. METHODS: A 76-year old female presented with pelvic pressure and the presence of a palpable vaginal bulge. She had significant bother and had previously failed use of a pessary. She wasnot sexually active, with no plans for future sexual activity. Her medical history was significant for coronary artery disease with prior myocardial infarction. She had high-grade vaginal vault prolapse, without occult incontinence. After discussing observation, pessaries, restorative and obliterative procedures, she elected to undergo colpocleisis. Following hydrodissection with lidocaine with epinephrine, a quadrant-based dissection was performed to remove the vaginal epithelium circumferentially. Following this, serial purse string sutures were used to reduce the prolapse, with meticulous hemostasis. The vaginal epithelium was then closed transversely. Next, a perineorrhaphy was performed. The midline was plicated and the perineal body reconstructed. RESULTS: The patient had an uncomplicated postoperative course. At six-week follow-up she had no evidence of recurrent prolapse and was voiding without difficulty. CONCLUSIONS: Colpocleisis can provide excellent anatomic and subjective outcomes. Our goal is to highlight pertinent technical considerations in order to optimize patient outcomes.

Relieving menstrual obstruction: surgical correction of vaginal agenesis.

INTRODUCTION AND HYPOTHESIS: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome includes vaginal agenesis with varied uterine development. The objective of this video is to illustrate our surgical technique to create a cervical and vaginal canal to relieve menstrual obstruction for a teenager with a functional uterus and vaginal agenesis. METHODS: Using vaginal dissection and a mini laparotomy, a sound placed through the fundus of the uterus created an endocervical and vaginal channel to relieve her menstrual obstruction. A Foley catheter stented the cervical canal and a red rubber chest tube catheter stented the vagina until epithelization was achieved. RESULTS: No complications were encountered. The patient was examined with intermittent hysteroscopy with gentle dilation of the cervix. She had the red rubber catheter removed at 3 months, and she started using a small dilator. Her menses were suppressed with a gonadotropin releasing-hormone agonist allowing for complete healing. She is now 17. Her vaginal canal is well-epithelialized. Hysteroscopy confirmed a patent endocervical canal and uterine cavity. CONCLUSION: MRKH is rare. A small percentage of affected women has a functional endometrium requiring intervention for menstrual obstruction. Full vaginal reconstruction may be considered, but creation of a small canal to provide menstrual relief can be a temporary solution in those not desiring sexual function.

Evaluation of the local carcinogenic potential of mesh used in the treatment of female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: To evaluate the carcinogenic potential of implanted synthetic mesh midurethral slings in the treatment of female stress urinary incontinence. METHODS: We identified female patients undergoing implantation of mesh materials for stress urinary incontinence at our institution from 1 January 2002 to 31 December 2012. This was accomplished by querying the medical records for CPT code 57288 ("sling operation for stress incontinence") and a subsequent chart review to identify patients who underwent synthetic mesh sling placement. Medical records were then evaluated for the documentation of bladder, urethral, vaginal, cervical, uterine or ovarian cancers via the International Classification of Disease (ninth edition) coding. A chart review of patients with a cancer diagnosis was performed for verification of the diagnosis and evaluation of the temporal relationship with sling placement. RESULTS: During the study period, 2,474 patients underwent polypropylene midurethral sling placement. The median age was 57 years (IQR 47, 69) and the median follow-up was 60 months (IQR 23.3, 94.9). Overall, 51 patients also had a cancer diagnosis (8 bladder cancers, 7 vaginal malignancies, 8 ovarian carcinomas, 26 endometrial cancers, 2 cervical malignancies); however, only 2 cancers (0.08 %, 2 out of 2,474) developed following sling placement (a vaginal melanoma 3 years after sling placement and an ovarian tumor 1 year after sling placement). No cases of sarcoma formation, bladder, urethral or squamous cell carcinomas were identified. CONCLUSIONS: With a median follow-up of 5 years after synthetic midurethral sling placement, development of pelvic malignancy was rare (0.08 %) and unlikely to be secondary to foreign body reaction from the implanted material.

Comparison of graft-reinforced repairs and suture repair using a novel biomechanical test.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine the feasibility of a novel biomechanical test for evaluating mesh-reinforced repair compared to suture-reinforced repair using an animal model. We hypothesized that the fatigue life of a mesh reinforced repair would be greater than that of xenograft reinforced repair and suture-only repair. METHODS: Wistar rats were randomly assigned to undergo a ventral hernia repair using sutures or one of the three mesh materials representative of incorporation, encapsulation and resorption host responses (Gynemesh, Pelvisoft and Surgisis®, respectively). All surviving animals were killed at 90 days and specimens containing the prosthesis-tissue interface were exposed to cyclic forces. The number of cycles to failure (fatigue life) was compared between groups using a Cox regression model. RESULTS: Of 40 randomly assigned animals, 11 died before 90 days. After randomizing an additional 5 rats, a total of 34 rats were killed at 90 days. The proportions of specimens that failed before 10,000 cycles were 25% (2/8), 50% (4/8), 62.5% (5/8) and 70% (7/10) in the Gynemesh, Surgisis, Pelvisoft, and suture control groups, respectively. In addition, the median number of cycles to failure was >10,000 in the Gynemesh group, >6,923 in the Surgisis group, 1133 in the Pelvisoft group and 741 in the control group. After adjustment for cross-sectional area, the risk of failure in the suture control group was higher than in all of the reinforced repair groups combined with an adjusted hazard ratio of 2.58 (95% CI 0.96 - 6.97), and was statistically significantly higher than in the Gynemesh group with an adjusted hazard ratio of 6.67 (95% CI 1.30 - 34.48). CONCLUSION: We present a novel biomechanical test that can be used to compare mesh materials in an animal model prior to use in humans. In this animal model, after adjusting for cross-sectional area, suture reinforced repair has a higher risk of failure than graft reinforced repair.

Assessing the learning curve of robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The aim was to evaluate the learning curve of robotic sacrocolpopexy, adjusted for surgical risk. METHODS: The charts of 145 robotic sacrocolpopexies performed by urogynecologists at Mayo Clinic, Rochester, MN, USA, from 2007 to 2013, were reviewed. Outcomes of interest included operative time, intraoperative complications, and postoperative complications with a Clavien-Dindo grade 2 or higher. Risk-adjusted cumulative summation analysis was performed by comparing a calculated complication risk score with observed patient outcomes, and then cumulatively recalculating the rate of expected vs observed complications after each procedure. Proficiency was defined as the point at which the surgeon's complication rates were better than expected, given the patient's risk factors. RESULTS: The median operative time decreased significantly, from 5.3 to 3.6 h, during the 7-year period, and plateaued after the first 60 cases. A higher ASA classification was associated with an increased risk of intraoperative complications (p = 0.02), and a higher Charlson comorbidity index was associated with an increased risk of intraoperative or postoperative complications (p = 0.01). In risk-adjusted CUSUM analyses, accounting for these factors, and for body-mass index and vaginal parity, proficiency was identified at 55 cases for intraoperative complications and 84 cases for intraoperative or postoperative complications. CONCLUSIONS: Operative time plateaued after the first 60 cases, whereas complication rates continued to decrease beyond this. Proficiency, as determined by a risk-adjusted CUSUM analysis for complication rates, was achieved after approximately 84 cases. Evaluation of postoperative complications in addition to intraoperative complications, in a risk-adjusted model, is critical in depicting the surgical learning curve.

Perioperative complications of robotic sacrocolpopexy for post-hysterectomy vaginal vault prolapse.

INTRODUCTION AND HYPOTHESIS: Open abdominal sacrocolpopexy has been the preferred treatment for post-hysterectomy vaginal vault prolapse. In light of the rise in popularity of less invasive robotic sacrocolpopexy, our objective was to compare perioperative complications of robotic vs open sacrocolpopexy. METHODS: This was a single-institution, retrospective cohort study of robotic and open sacrocolpopexies. Robotic sacrocolpopexies performed between 1 January 2007 and 31 December 2009 were compared with open cases performed between 1 January 2002 and 31 December 2006. Baseline and intraoperative variables of the groups were compared. Complications were compared univariately and in a multivariable logistic regression model to adjust for prior transabdominal surgery. RESULTS: A total of 50 robotic and 87 open sacrocolpopexies were analyzed. Baseline characteristics were similar, but patients in the open group had more prior transabdominal surgeries. The robotically assisted group had decreased estimated blood loss (median, 100 mL vs 150 mL; P = 0.002) and hospital stay (median, 2 days vs 3 days; P < 0.001), but increased operative time (median, 4.6 vs 2.9 h; P < 0.001), cystotomy (10.0 % [5 out of 50] vs 1.1 % [1 out of 87]; P = 0.02), and vaginotomy (24.0 % [12 out of 50] vs 5.7 % [5 out of 87]; P = 0.003). Two patients in the robotically assisted group had postoperative hernia. There were no differences in rates of ureteral or bowel injury, urinary tract infection, ileus, bowel obstruction, or overall complications. CONCLUSIONS: Overall complication rates of robotic and open sacrocolpopexy were not significantly different. The robotically assisted group experienced shorter hospital stay but increased operative times and increased incidence of cystotomy and vaginotomy, possibly reflecting the learning curve of robotic sacrocolpopexy.