Marjolin's Ulcer: Mesh-Related Vaginal Cutaneous Fistula With Superimposed Osteomyelitis and Neoplastic Transformation.

Marjolin's ulcer is a rare, often aggressive squamous cell malignancy identified in previously injured areas or those affected by chronic inflammation. It often develops in deep wounds that are slow to heal or allowed to heal by secondary intention. Few reports and small case series about Marjolin's ulcer have been published. We present a unique case with well-differentiated keratinized squamous cell carcinoma arising from a mesh-related vaginocutaneous fistula with superimposed osteomyelitis. The risk of cancerous transformation leading to Marjolin's ulcer in non-healing traumatic wounds is 8.1% and 2.6% in a fistula associated with purulent-inflammatory bone diseases. Approximately 1.7% of chronic cutaneous ulcers undergo neoplastic transformation, with a disposition to squamous cell carcinoma. Women experiencing mesh complications may require multiple procedures to address these issues and, therefore, should have them addressed in a timely manner to allow for the best patient outcome. Treatment optimization on a whole should incorporate the goals outlined by the American Urogynecologic Society and the International Urogynecological Association. These include the use of relevant evidence to help guide the management of mesh complications as well as identifying the gaps in currently available evidence, developing a treatment algorithm to be used for shared decision making, and identifying provider and healthcare facility characteristics that may optimize treatment outcomes specific to mesh complications.

Robotic Placement of the FENIX Continence Restoration System in a Patient with Previous Radiation to the Pelvis: A Case Report.

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patient's risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patient's quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.

The Fenix System for Fecal Incontinence: An Overview and Surgical Demonstration.

STUDY OBJECTIVE: This video shows a new technique for the surgical management of fecal incontinence using the Fenix Continence Restoration System (TORAX Medical Inc, Shoreview, MN) in 2 patients. DESIGN: A step-by-step explanation of the video using videos and pictures (educational video) for surgeons (Canadian Task Force classification III). SETTING: The use of the Fenix System received United States Food and Drug Administration approval under a humanitarian device exemption and can be used with institutional review board approval in patients who have failed previous medical and surgical management of fecal incontinence. The device is a small, flexible band of interlinked titanium, magnetic beads on a titanium string that is placed using a perineal approach around the anal canal. Increased intra-abdominal pressure opens the beads to allow for the passage of stool. INTERVENTIONS: Placement of the device was performed in 2 patients. Case 1 is a 63-year-old woman with a long-standing history of fecal incontinence who failed sphincteroplasty, sacral neuromodulation, and an artificial sphincter cuff and pump. Case 2 is a 60-year-old woman with a long-standing history of fecal incontinence secondary to radiation therapy for rectal cancer who failed physical therapy and sacral neuromodulation. CONCLUSION: Both Fenix Continence Restoration Systems were placed successfully. Long-term postoperative effectiveness is currently being evaluated.

Nonoperative management of an anastomotic leak following rectosigmoid resection and anastomosis for Stage IV endometriosis.

Anastomotic leakage is a dreaded complication of gastrointestinal surgery. The complication is difficult to manage and is associated with prolonged hospitalizations and increased morbidity and mortality. We present the nonsurgical management and the use of a fibrin sealant for an anastomotic leak that followed rectosigmoid resection and anastomosis for Stage IV endometriosis. This approach requires a clinically stable patient who is willing to follow-up over a prolonged period of time until the leak is completely sealed. Tissue sealants can be considered when an air leak or fistulous tract persists despite drainage and antibiotics.

Preventing slide in Trendelenburg position: randomized trial comparing foam and gel pads.

To compare patient slide in Trendelenburg position using egg-crate foam or gel pad. This randomized trial compared slide on friction pads during Trendelenburg position for robotic and laparoscopic gynecologic procedures in 61 patients at the Mayo Clinic Florida between March 11, 2010 and May 31, 2011. Data was analyzed using Student's t test with significance defined as p ≤ 0.05. There was no significant difference in mean slide according to pad type (foam 3.0 ± SD 2.1 cm; gel 4.5 ± SD 4.0 cm, p = 0.08). Minor complaints occurred in 10 % of patients, and did not differ by group (p = 0.4). Most complaints (98 %) were transient shoulder or neck pain. A single patient had both transient right hand numbness and right lateral thigh paresthesia. We assessed outcomes by chart review from the inpatient care and postoperative evaluation notes (mean 44 ± SD 17 days), and by review of any intervening notes that occurred before the study's end (mean 345 ± SD 116 days). Trendelenburg-related slide is equivalent on either egg-crate foam or gel pad.

Implantable neuromodulation for urinary urge incontinence and fecal incontinence: a urogynecology perspective.

Implantable sacral nerve stimulation is a minimally invasive, durable, and reversible procedure for patients with urinary urge and fecal incontinence who are refractory to conservative therapy. The therapy is safe compared with other surgical options. An intact external or internal rectal sphincter is not a prerequisite for success in patients with fecal incontinence.

Robotic-assisted sacrocolpopexy: technique and learning curve.

BACKGROUND: Laparoscopic sacrocolpopexy (LSCP) offers a minimally invasive approach for treating vaginal vault prolapse. The Da Vinci robotic surgical system may decrease the difficulty of the procedure. The objective of this study was to describe the surgical technique of robotic-assisted sacrocolpopexy (RASCP) and evaluate its feasibility, safety, learning curve, and perioperative complications. METHODS: Eighty patients underwent RASCP between November 2004 and June 2007. Robotic dissection of the planes between the bladder and vagina anteriorly and between the vagina and rectum posteriorly was performed. A peritoneal incision was made to expose the sacral promontory and extended down to the vaginal apex. A Y-shaped mesh was sutured to the anterior and posterior surfaces of the vagina. The tail end of the mesh was sutured to the sacral promontory. Intracorporeal knot tying was used in all sutures. The peritoneal incision was closed to cover the mesh using a running suture. RESULTS: Mean operative time was 197.9 [standard deviation (SD) 66.8] min. After completion of the first ten cases, mean operative time decreased by 25.4% [64.3 min, 95% confidence interval (CI) 16.1-112.4 min, p < 0.01]. Two (2.5%) patients had injury to the bladder, one (1.2%) patient had a small bowel injury, and one (1.2%) patient had a ureteric injury. Postoperatively, five (6%) patients developed vaginal mesh erosion, one (1.2%) patient developed a pelvic abscess, and one (1.2%) patient had postoperative ileus. Four (5%) cases were converted to laparotomy. Mean follow-up period was 4.8 months (range 1-24 months). CONCLUSIONS: RASCP is a feasible procedure with acceptable complication rates and short learning curve.

Long-term urinary continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings.

PURPOSE: We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. MATERIALS AND METHODS: A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. RESULTS: A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). CONCLUSIONS: Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.

Lumbar peritoneal shunting with video-laparoscopic assistance: a useful technique for the management of refractory postoperative lumbar CSF leaks.

BACKGROUND: Cerebrospinal fistulas and pseudomeningoceles can occur after lumbar spinal surgery, and are sometimes refractory to direct repair, external drainage, and blood patches. The authors report a technique for cerebrospinal fluid (CSF) diversion from the lumbar spine to the peritoneum to assist with the management of these difficult situations. METHODS: Using video-laparoscopic assistance, two shunts are placed from the lumbar region into the peritoneal cavity: first, a lumbar subarachnoid space to peritoneum shunt; and second, a meningocele cavity to peritoneum shunt. Patients are ambulated immediately after the procedure. External drains are not used. RESULTS: Four patients with refractory CSF leaks were successfully managed with this technique. Complications associated with prolonged bedrest and external drains were avoided. Ancillary procedures were minimized, and hospital stay was shortened. Laparoscopic assistance offered verification of accurate placement of the peritoneal catheter and shortened operative times. CONCLUSIONS: Dual lumbar peritoneal shunts (intrathecal-peritoneal and meningocele cavity-peritoneal), placed with laparoscopic assistance, proved effective in the management of four patients with postoperative lumbar CSF leaks, who had failed to respond to conventional treatment.

Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction.

OBJECTIVE: The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction. STUDY DESIGN: Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis). RESULTS: All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding. CONCLUSION: The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence.

Sacral neuromodulation: new applications in the treatment of female pelvic floor dysfunction.

PURPOSE OF REVIEW: The first sacral nerve stimulators implanted by Tanagho and Schmidt (1981) were performed for the indications of urinary urge incontinence, urgency-frequency, and nonobstructive urinary retention. Since that time, observations have been made for benefits beyond voiding disorders. These additional benefits have included re-establishment of pelvic floor muscle awareness, resolution of pelvic floor muscle tension and pain, decrease in vestibulitis and vulvadynia, decrease in bladder pain (interstitial cystitis), and normalization of bowel function. RECENT FINDINGS: Therapy for fecal incontinence in patients with a structurally intact sphincter mechanism appears to be very promising. Investigators agree that there is a role for sacral nerve stimulation in patients with urge fecal incontinence that have failed conservative efforts. Objective manovolumetric testing shows an increase in resting pressure, an increase in voluntary contraction pressure, a decrease in rectal volumes which cause first urge, a decrease in rectal volume to initiate first urge to defecate, and an increase in duration of maximum squeeze pressure. Intractable interstitial cystitis is defined as patients that have failed conventional therapy. Historically, the only option remaining was extirpative surgery or diversion. Maher et al. reported on patients with intractable interstitial cystitis who had undergone sacral nerve stimulation. They found that 73% of these patients had a reduction in pelvic pain, daytime frequency, nocturnal urgency and an increase in average voided volumes. The final area of interest concerns refractory pelvic pain. Siegal et al. reported a decrease in severity, number of hours of pain, and improved quality of life measures in patients who underwent transforamenal sacral nerve stimulations. These patients had all failed conventional pain therapy. SUMMARY: While the data are encouraging in these new arenas of pelvic floor disorders, investigators acknowledge the need for multicenter, statistically powered studies to evaluate the validity of these findings.