Evaluation and Resection of a Longitudinal Vaginal Septum in an Adult.

OBJECTIVE: The objective of this video is to demonstrate the diagnosis, evaluation, and techniques for surgical management of a longitudinal vaginal septum, a rare müllerian anomaly. DESIGN: This is a stepwise demonstration of evaluation and surgical techniques with video narration. SETTING: The incidence of müllerian defects, which can include any anomaly in the fallopian tube, uterus, cervix, or vagina, has been estimated to be 2% to 4% [1]; 30% to 40% of patients with müllerian defects also have associated renal anomalies [1,2]. In normal development, the müllerian ducts fuse at 10 weeks' gestation and the septum between the 2 ducts is absorbed in a caudal to cephalad direction [3]. The exact incidence of complete longitudinal vaginal septa is unknown as they are very rare [4]. Longitudinal vaginal septa may cause dyspareunia, inability to have penetrative intercourse, labor dystocia, or hygiene issues and be very emotionally distressing for patients [5]. INTERVENTIONS: Preoperative evaluation of an adult with longitudinal vaginal septum that included a careful physical examination and abdominal and pelvic imaging. Intraoperative resection with key strategies: (1) placing a Foley catheter to help avoid urinary tract injuries and (2) intermittent rectal examinations to retract the rectum away from the plane of dissection. CONCLUSION: Patients who present with longitudinal vaginal septa should undergo evaluation for uterine and renal anomalies. Here, we show that resection of longitudinal vaginal septa in adults is feasible and appropriate for patients who present with inability to have penetrative intercourse. Intraoperatively, care should be taken to avoid injuring the rectum or urinary tract.

Transvaginally Adjustable Apical Suspension and Compartment-Specific Tensioning in Vaginal Natural-Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Cadaveric and Live Patient Experience.

Objective: This article provides a systematic approach to performing a vaginal natural-orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy (SCP) to create an anatomically aligned vaginal axis, an intraoperatively adjustable apical suspension, and variable compartment tensioning. Methods: The technique presented for vNOTES SCP focuses on: (1) retroperitoneal tunneling; (2) direct sacrum access below the S-1 level, using uterosacral-ligament guidance; (3) transvaginal tensioning of the mesh to ensure both adequate vaginal length and cuff elevation using the DZOH apical-suspension technique; (4) circumvention of intrapelvic laparoscopic suturing; and (5) near-total peritoneal coverage of the mesh arms. Results: This detailed description of a successful novel technique to perform vNOTES SCP was based on cadaveric experience as well as in live patients that is reproducible on living patients. Conclusions: This apical suspension technique for vNOTES SCP may be a viable, reproducible, safe, and efficient transvaginal alternative to the commonly practiced minimally invasive approaches that involve abdominal-port placements. (J GYNECOL SURG 40:116).

Assessment of patient satisfaction with home vs office indwelling catheter removal placed for urinary retention after female pelvic floor surgery: a randomized controlled trial.

BACKGROUND: Postoperative urinary retention is burdensome for patients. We seek to improve patient satisfaction with the voiding trial process. OBJECTIVE: This study aimed to assess patient satisfaction with location of indwelling catheter removal placed for urinary retention after urogynecologic surgery. STUDY DESIGN: All adult women who were diagnosed with urinary retention requiring postoperative indwelling catheter insertion after undergoing surgery for urinary incontinence and/or pelvic organ prolapse were eligible for this randomized controlled study. They were randomly assigned to catheter removal at home or in the office. Those who were randomized to home removal were taught how to remove the catheter before discharge, and were discharged home with written instructions, a voiding hat, and 10-mL syringe. All patients had their catheter removed 2 to 4 days after discharge. Those patients who were allocated to home removal were contacted in the afternoon by the office nurse. Subjects who graded their force of urine stream 5, on a scale of 0 to 10, were considered to have safely passed their voiding trial. For patients randomized to the office removal group, the voiding trial consisted of retrograde filling the bladder to maximum they could tolerate up to 300 mL. Urinating >50% of instilled volume was considered successful. Those who were unsuccessful in either group had catheter reinsertion or self-catheterization training in the office. The primary study outcome was patient satisfaction, measured based on patients' response to a question, "How satisfied were you with the overall removal process of the catheter?" A visual analogue scale was created to assess patient satisfaction and 4 secondary outcomes. A sample size of 40 participants per group were needed to detect a 10 mm difference in satisfaction between groups on the visual analogue scale. This calculation provided 80% power and an alpha of 0.05. The final number accounted for 10% loss to follow up. We compared the baseline characteristics, including urodynamic parameters, relevant perioperative indices, and patient satisfaction between the groups. RESULTS: Of the 78 women enrolled in the study, 38 (48.7%) removed their catheter at home and 40 (51.3%) had an office visit for catheter removal. Median and interquartile range for age, vaginal parity, and body mass index were 60 (49-72) years, 2 (2-3), and 28 (24-32) kg/m2, respectively, in the overall sample. Groups did not differ significantly in age, vaginal parity, body mass index, previous surgical history, or type of concomitant procedures. Patient satisfaction was comparable between the groups, with a median score (interquartile range) of 95 (87-100) in the home catheter removal group and 95 (80-98) in the office catheter removal group (P=.52). Voiding trial pass rate was similar between women who underwent home (83.8%) vs office (72.5%) catheter removal (P=.23). No participants in either group had to emergently come into the office or hospital due to inadequate voiding afterwards. Within 30 days post operatively, a lower proportion of women in the home catheter removal group (8.3%) had urinary tract infection, compared to patients in the office catheter removal group (26.3%) (P=.04). CONCLUSION: In women with urinary retention after urogynecologic surgery, there is no difference in satisfaction concerning the location of indwelling catheter removal when comparing home and office.

Sling plication for persistent stress urinary incontinence after midurethral sling.

INTRODUCTION AND HYPOTHESIS: Persistent or recurrent stress urinary incontinence after midurethral sling placement is not uncommon. Treatment options include placement of a second midurethral sling, autologous fascial sling, retropubic urethropexy, or urethral bulking. Shortening of the sling by plication has also been suggested as an alternative option which may reduce operative time, cost, risk of trocar injury, and mesh burden. In this video, we aimed to demonstrate our technique and experience on sling plication. METHODS: The key steps of the procedure are as follows: (1) suburethral incision and sharp dissection to identify the sling; (2) mobilization of the suburethral portion of the sling; (3) plication with two interrupted, horizontal sutures placed 1 cm laterally on each side; (4) application of upward pressure while tying the sutures and tensioning the sling. In our experience, we have found this technique to be most successful for retropubic slings, especially when performed within 2-12 weeks of the initial surgery. CONCLUSIONS: Sling plication is an effective and minimally invasive option to treat persistent stress urinary incontinence after failed midurethral sling procedures. It avoids additional mesh burden or more invasive retropubic surgery and should be offered as a treatment option for appropriately counseled patients.

Current state of bladder diary: a survey and review of the literature.

INTRODUCTION AND HYPOTHESIS: The objectives of this study are (1) to assess practice patterns among urogynecology/female pelvic medicine and reconstructive surgery (FPMRS) providers regarding the use of bladder diaries (BD) and (2) to review the literature regarding BD. METHODS: For the first objective, a survey was emailed to United States-based urogynecology providers in 2019 querying frequency of use of bladder diaries (FBD), indications, problems, patient education methods, and perception of utility. Chi-square tests and multiple logistic regression were performed. For the second objective, we reviewed literature published in English by searching the terms "voiding," "bladder," or "incontinence," in combination with "diary," "log," or "questionnaire." RESULTS: A total of 371 of 851 (43.5%) contacted providers responded. Nearly 80% were attending physicians, 75.5% of whom completed the FPMRS fellowship; 20.8% of all respondents and nearly 25% of fellowship-trained attendings reported FBD <20% in the last year. FPMRS providers were more likely to report FBD >80%. A total of 97.5% of respondents cited difficulty in using BD. Most (71.6%) taught patients to use BD themselves or shared responsibility with a nonphysician staff member (53.4%). BD is a validated and valuable instrument; however, there are obstacles to its use. Despite recent innovations including electronic and automated BD, there is a paucity of data regarding the provider-viewed challenges in implementing BD. CONCLUSIONS: The literature supports the use of BD; however, many survey respondents, including fellowship-trained attendings, never or rarely use BD. Most respondents reported difficulty in using BD. More research is needed to improve the ease, accuracy, and widespread adaptation of BD use in clinical practice.

Voided volume for postoperative voiding assessment following prolapse and urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the safety and accuracy of voided volume with the standard retrograde fill approach for voiding assessment after pelvic floor surgery. METHODS: This cohort represents all women in our repository who underwent postoperative voiding assessment following procedures for pelvic floor disorders between September 2011 and June 2014. One surgeon utilized a spontaneous voiding (SV) protocol and allowed any patient who voided 150 ml or more at one time to pass the trial. The other surgeon used a retrograde fill (RF) protocol. This involved instilling the bladder with 300 ml of water or until maximum capacity immediately after the outpatient procedures and on the first postoperative day for hospitalized patients. For this protocol, a voided volume of 200 ml was considered sufficient to pass the trial. RESULTS: In this cohort, 431 women had a voiding trial with SV, and 318 with RF. The groups were similar with respect to baseline characteristics but more women in the RF group had a sling-only procedure. The failure rates of the RF (22.8%) and SV (20.0%) groups were similar (p = 0.46). Among women who passed the voiding trial, similar percentages of women returned with urinary retention and needed catheter insertion after the RF (1.6%) and SV (0.9%) methods (p = 0.65). CONCLUSION: Spontaneous voiding trial based on a minimum voided volume of 150 ml is a safe and reliable alternative to the retrograde fill method after female pelvic floor procedures.

Optimizing the robotic surgery team: an operations management perspective.

INTRODUCTION AND HYPOTHESIS: To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions. METHODS: All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify 'optimal' surgical team configuration. RESULTS: The database included 359 consecutive RASCPs, all performed for stage III-IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3 years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7 kg/m2. A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively. CONCLUSION: Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.

Association of Race/Ethnicity with Surgical Route and Perioperative Outcomes of Hysterectomy for Leiomyomas.

STUDY OBJECTIVE: To evaluate the associations among race/ethnicity, route of surgery, and perioperative outcomes for women undergoing hysterectomy for uterine leiomyomas. DESIGN: Retrospective cohort study. SETTING: Multistate. PATIENTS: Women who underwent hysterectomies for leiomyomas from the American College of Surgeons National Surgical Quality Improvement Program database, 2014 to 2017. INTERVENTIONS: None. Exposures of interest were race/ethnicity and route of surgery. MEASUREMENTS AND MAIN RESULTS: Racial/ethnic variation in route of surgery and perioperative outcomes. Propensity score matching was employed to control for possible confounders. We identified 20 133 women who underwent nonemergent abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or vaginal hysterectomy (VH) for leiomyomas. We defined minimally invasive hysterectomy (MIH) as LH or VH. Black women were more likely to have open surgery (AH vs MIH adjusted odds ratio [aOR], 2.22; 95% confidence interval [CI], 2.07-2.38; AH vs VH aOR, 1.79; 95% CI, 1.54-2.08; AH vs LH aOR, 2.27; 95% CI, 2.13-2.44) than white women. Likewise, Hispanic women were more likely to have open surgery (AH vs MIH aOR, 1.76; 95% CI, 1.58-1.96; AH vs LH aOR, 1.82; 95% CI, 1.61-2.00) than white women. Black women were more likely to experience any complication after hysterectomy (AH aOR, 1.54; 95% CI, 1.31-1.80; VH aOR, 1.65; 95% CI, 1.02-2.68; LH aOR, 1.37; 95% CI, 1.13-1.66) than white women. Hispanic women were less likely than white women to experience major complications after VH (aOR, 0.28; 95% CI, 0.08-0.98). Compared with white women, the mean length of stay was longer for black women who underwent AH or LH. The mean total operation time was higher for all minority groups (except for Asian/other undergoing AH) regardless of surgical approach. CONCLUSION: Women of minority race/ethnicity were more likely to undergo abdominal rather than MIH for leiomyomas. Even when controlling for route of surgery, they were more likely to experience perioperative complications.

Circumferential urethral diverticulum: a surgical conundrum.

INTRODUCTION AND HYPOTHESIS: Excision of a circumferential diverticulum may be challenging as its extension into the dorsal aspect of the urethra makes access complicated. METHODS: A 69-year-old woman with a history of Stage 3C ovarian cancer on chemotherapy presented with a 3-week history of severe dysuria and suprapubic pain. T2-weighted pelvic magnetic resonance imaging (MRI) showed a circumferential diverticulum extending over the dorsal midurethra without evidence of urethral communication. As conservative measures including bladder instillations failed, she underwent surgical excision of this multilocular circumferential diverticulum. The diverticulum was identified and excised in segments. To achieve optimal excision, we incised around and dorsal to the urethral meatus into the retropubic area. Finally, a communicating tract from the ventral loculation of the diverticulum to the urethra was identified. The communication was obliterated, and the urethra was repaired in two layers and reinforced with a fibromuscular flap. The fluid tight seal was confirmed by retrograde filling of the bladder and cystourethroscopy. RESULTS: The patient was symptom free at 6-week and 6-month visits. CONCLUSION: This video highlights the steps required to successfully excise a complex circumferential diverticulum that extends over the dorsal midurethra and has a communication with the urethral lumen.

Hysterectomy at the time of colpocleisis: a decision analysis.

INTRODUCTION AND HYPOTHESIS: Colpocleisis is an obliterative procedure for the treatment of pelvic organ prolapse (POP) with success rates nearing 100 %. Concomitant hysterectomy is commonly performed to avoid potential difficulty or delay in diagnosis and management of endometrial cancer (EMC). The objective was to assess the utility of vaginal hysterectomy at the time of a colpocleisis using decision analysis. METHODS: A decision analysis model was constructed to compare the outcomes of Le Fort colpocleisis (C) with those of colpocleisis and concomitant vaginal hysterectomy (CH). Probability and utility values from published data and expert opinions were utilized. As EMC risk changes with age, the total expected utility for each alternative was calculated for each decade using the rollback method. Sensitivity analysis was performed using Monte Carlo simulation. When evaluating specifically the risk of developing EMC in those patients with uterine conservation (C) and the risk of laparotomy in patients undergoing CH, one-way sensitivity analysis was used to determine a threshold for decision reversal. Two-way sensitivity analysis determined a threshold for complications common to both C and CH. RESULTS: The expected overall utility for C was higher than for CH for all ages 30-90 years. This difference was statistically significant for ages 40-90, favoring C. The Monte Carlo simulation results confirmed that the difference between the two alternatives was statistically significant. Multiple one-way sensitivity analyses confirmed model robustness. CONCLUSIONS: Colpocleisis should be preferred to CH. Concomitant hysterectomy commonly performed for cancer may be justified in patients younger than 40 years of age.

POP-Q 2.0: its time has come!

The Pelvic Organ Prolapse Quantification (POP-Q) system has been critical in the growth of the urogynecology field. It is time to revise the POPQ to make it simpler, more intuitive, more precise, less arbitrary, and more practical.

Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis.

INTRODUCTION AND HYPOTHESIS: A recent randomized controlled trial (RCT) with and without prophylactic antibiotics (pABX) for midurethral slings (MUS) was terminated early owing to lower than predicted infectious complications in both groups. Adequate power required an unattainable sample size. Because of low infectious risks, omitting pABX may be justified. Since an RCT was not feasible, we aimed to use decision analysis modeling to determine if pABX are necessary for MUS. METHODS: We created a decision analysis model comparing 1-year quality adjusted life years (QALYs) between women who do and do not receive pABX for MUS. The model included complications that might differ depending on whether antibiotics were given, such as allergic reaction to pABX (mild/severe), vulvovaginal candidiasis, urinary tract infections including pyelonephritis, pseudomembranous colitis, wound infection, and mesh erosion. Multiple one-way sensitivity analyses confirmed model robustness. RESULTS: One year after MUS, women who did not receive pABX had higher average QALYs than pABX (0.989 vs 0.977). This difference is less than published minimally important differences (MID) for utilities, suggesting that the strategies are comparable. Ultimately, pABX increased some complications and reduced others with an overall minimal effect on outcomes. Very few thresholds were identified, indicating model robustness and strengthening our conclusions. CONCLUSIONS: Women had slightly higher overall QALY when pABX were not given, but not greater than the MID. Since infectious complications are rare, our model suggests that pABX might be an unnecessary precaution because of similar outcomes with and without pABX.

Women's perceptions about female reproductive system: a survey from an academic obstetrics and gynecology practice.

OBJECTIVE: To assess women's knowledge about female reproductive system and the demographic factors that may influence their perceptions. STUDY DESIGN: In this cross-sectional study, all qualifying adult women at our academic practice were asked to complete a self-administered anonymous questionnaire about the effects of female reproductive system between June and August 2009. We assessed the accuracy of their knowledge and analyzed the effect of demographic factors. RESULTS: The majority of the 500 participants were in 18- to 59-year age range (93 %), Caucasian (81 %), married (56 %), college graduates (74 %) and had private insurance (82 %). Mean correct score was 63 ± 20 %. In univariate analysis, those respondents who were older, Caucasian, and had private insurance scored significantly higher (p < 0.05) When all the variables were entered in a fractional logit model, only age, race and reason for the visit remained as independent predictors for a better overall score in this survey. Twenty-nine percent of the participants thought hysterectomy included removal of ovaries and tubes. About a quarter of the respondents thought menstrual function would continue after hysterectomy. The question for whether removal of the uterus resulted in climacteric changes was correctly answered only by 34 %. While 59 % of women did not agree that removing the entire uterus eliminated the cervical cancer risk, 66 % concluded that they would continue to need Pap smears after total hysterectomy. CONCLUSION: Women's knowledge about female reproductive system is limited, especially for those who are younger and from a minority.

Effect of Educational Video on Patient Adherence and Completeness of Voiding Diaries: A Randomized Trial.

IMPORTANCE: Voiding diaries are clinically useful tools for elucidating the etiology of lower urinary tract symptoms. The utility of voiding diaries is challenged by low return rate and incomplete or inaccurate data entry. OBJECTIVE: The objective was to determine the effect of the use of an educational video on patient adherence, completeness of intake and voiding diaries, and patient satisfaction. STUDY DESIGN: In this trial, patients who were asked to complete an intake and voiding diary in a urogynecology clinic were randomized to receive standard education or enhanced education with an instructional video on how to complete the diary. Patients returned the diaries at their follow-up visits in the clinic. The primary outcome was the return rate of the diaries. Upon follow-up, patients filled out a survey reporting their satisfaction with instructions received. Diaries were graded by 3 blinded experts. RESULTS: Eighty-five patients were enrolled, 42 in the standardized instructions arm and 43 in the video arm. A total of 26 patients (30.6%) filled out and returned an intake and voiding diary. Between groups, there was no difference in the rate of return of the diaries ( P = 0.59) or in completeness of the returned voiding diaries ( P = 0.60). The educational video did not change satisfaction between the groups; patients reported identical satisfaction between groups. CONCLUSIONS: The addition of an instructional video on how to complete an intake and voiding diary did not increase patients' rate of return, completeness of diaries, or satisfaction with instructions provided to complete the diary.

Asymptomatic microscopic hematuria in women requires separate guidelines.

The guidelines recently updated by the American Urological Association for the evaluation of asymptomatic microscopic hematuria (AMH) are based on data derived predominantly from men. They cannot be reliably applied to females as the epidemiology of AMH is gender dependent. The research on women in this area has been limited. It is incumbent on the experts in the field of female pelvic medicine to advance the science and develop management algorithms for AMH in women.

Vaginal myofibroblastoma with prostatic glands: is there an association with tamoxifen use? A case report.

BACKGROUND: Both ectopic prostate tissue in the female genital tract and vaginal myofibroblastoma have rarely been reported in the literature. Tamoxifen use has been associated with the development of vaginal myofibroblastoma. CASE: A 76-year-old, multiparous woman who had taken tamoxifen for breast cancer presented with postmenopausal bleeding and a vaginal mass. Endometrial work-up revealed a benign polyp, and the polypoid tumor in the vagina was found to be a myofibroblastoma harboring ectopic prostatic glands. CONCLUSION: To our knowledge this is the first case of these two rare pathologic entities occurring together. Of note, this patient also had a history of tamoxifen therapy, like some of the previous patients with vaginal myofibroblastoma.

Effect of obesity on perioperative outcomes of laparoscopic hysterectomy.

OBJECTIVE: To compare the effect of obesity on perioperative outcomes in women undergoing laparoscopic hysterectomy. STUDY DESIGN: In this retrospective cohort study, perioperative outcomes of all women who underwent laparoscopic supracervical hysterectomy (LSH) or total laparoscopic hysterectomy (TLH) for benign conditions were compared between obese (body mass index > or = 30 kg/m2) and nonobese women. RESULTS: Baseline characteristics were similar between 320 (33.0%) obese and 550 (67%) nonobese women except for race and the rates of hypertension and diabetes. The adjusted rates of urinary tract injury, vaginal cuff dehiscence, postoperative fever, and ileus were similar between the groups. For obese women, however, bleeding requiring transfusion was almost 3-fold (3.1 vs. 1.1%, adjusted odds ratio [AOR] 2.93, 95% confidence interval [CI] 1.10-7.80) and laparotomy risk was approximately 2-fold (7.5 vs. 3.5%, AOR 2.35, 95% CI 1.30-4.24) increased. The rate of urinary tract injury was 3.2% when obese women had TLH, but it was 0.3% for LSH performed on nonobese women. Of all 7 cuff dehiscences, 5 (71%) occurred in nonobese women undergoing TLH. CONCLUSION: Obesity increased the risk of bleeding requiring transfusion and conversion to laparotomy but did not influence the other perioperative complications. On subgroup analysis, LSH in nonobese women seems to result in best outcomes.

Massive subcutaneous emphysema in robotic sacrocolpopexy.

The advent of robotic surgery has increased the popularity of laparoscopic sacrocolpopexy. Carbon dioxide insufflation, an essential component of laparoscopy, may rarely cause massive subcutaneous emphysema, which may be coincident with life-threatening situations such as hypercarbia, pneumothorax, and pneumomediastinum. Although the literature contains several reports of massive subcutaneous emphysema after a variety of laparoscopic procedures, we were not able to identify any report of this complication associated with laparoscopic or robotic sacrocolpopexy. Massive subcutaneous emphysema occurred in 3 women after robotic sacrocolpopexy in our practice. The patients had remarkable but reversible physical deformities lasting up to 1 week. A valveless endoscopic dynamic pressure system was used in all 3 of our cases. Our objective is to define the risk of massive subcutaneous emphysema during robotic sacrocolpopexy in light of these cases and discuss probable predisposing factors including the use of valveless endoscopic dynamic pressure trocars.