A novel transvaginal approach to correct recurrent apical prolapse after failed sacral colpopexy: case series.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to describe the transvaginal approach utilizing the existing sacral colpopexy (SC) graft for recurrent apical prolapse following failed SC. METHODS: Twenty-two patients with recurrent vaginal vault prolapse following a prior SC were treated between January 2000 and December 2009. Twelve patients had a standard uterosacral ligament cuff suspension (USLS) performed. In ten patients, the vaginal cuff was suspended to the left uterosacral ligament and reattached to the graft material from the prior SC. One of these ten subsequently failed and a standard USLS was performed. Patient characteristics, preoperative pelvic floor assessment, operative information, and postoperative follow-up were collected. Cases in which the graft material was used were compared with those undergoing standard USLS. RESULTS: Demographic characteristics and preoperative Baden-Walker scores were similar. Of 23 cases, 21 (91 %) were a consequence of graft separation from the vagina and not the sacrum. Two of nine patients with follow-up where the SC graft was utilized transvaginally had recurrent prolapse. One required reoperation. Of 13 patients in the group that underwent traditional USLS, 2 had asymptomatic recurrent anterior prolapse; neither required additional surgery. CONCLUSIONS: A transvaginal surgical approach for recurrent vaginal prolapse after a history of failed abdominal SC should be considered. If feasible, the SC graft material can be used when performing USLS instead of the right uterosacral ligament for these patients with a prior history of abdominal SC.

A randomized comparison of bupivacaine versus saline during placement of tension-free vaginal tape.

OBJECTIVES: To compare postoperative urinary retention and pain control when bupivacaine versus saline for hydrodissection is used while placing tension-free vaginal tape midurethral slings. METHODS: A prospective, randomized, double-blind trial was performed after institutional review board approval. Sixty women were randomized to receive bupivacaine or saline for hydrodissection. Subjects and research team were blinded to subject assignments. Group characteristics were compared using the Student t test, the χ test, and the Mann-Whitney U test. Proportions of subjects with a successful postoperative voiding trial along with measurements of postoperative pain and analgesic use were compared using similar appropriate tests. The study was powered to detect differences in voiding trial success from an estimated 58% to greater than 90% with P < 0.05 and 0.8 power using 25 subjects per group. RESULTS: Thirty patients were allocated to each group. One subject in the saline-only group was excluded. Group characteristics were not different. After surgery, pain medication use (20/30 vs 25/29 for bupivacaine vs saline only; P = 0.08), pain scores (36 ± 22 vs 31 ± 24; P = 0.49), and successful voiding trials did not differ (14/30 vs 19/29; P = 0.14), whereas postvoid residuals did differ (225 ± 180 mL vs 140 ± 147 mL; P = 0.043). CONCLUSIONS: Bupivacaine was not seen to improve immediate postoperative pain after placement of a tension-free vaginal tape. It did not increase the risk of failing a postoperative voiding trial. Without an obvious benefit, the use of an additional medicine is not supported. We suggest saline alone be used for hydrodissection.

Alterations in pelvic floor muscles and pelvic organ support by pregnancy and vaginal delivery in squirrel monkeys.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to measure the effects of pregnancy and parturition on pelvic floor muscles and pelvic organ support. METHODS: Levator ani, obturator internus, and coccygeus (COC) muscle volumes and contrast uptake were assessed by MRI of seven females prior to pregnancy, 3 days, and 4 months postpartum. Bladder neck and cervix position were measured dynamically with abdominal squeezing. RESULTS: The sides of three paired muscles were similar (p > 0.66). COC volumes were greater (p < 0.004) after parturition than before pregnancy or after recovery. COC contrast uptake increased (p < 0.02) immediately after delivery. Bladder neck position both in the relaxed state and abdominal pressure descended (p < 0.04) after delivery and descended further (p < 0.001) after recovery. Cervical position in the relaxed state before delivery was higher (p < 0.001) than postpartum but was unchanged (p = 0.50) with abdominal pressure relative to delivery. CONCLUSION: In squirrel monkeys, coccygeus muscles demonstrate the greatest change related to parturition, and parturition-related bladder neck descent seems permanent.

Preferences and concerns for delivery: an antepartum survey.

Little is known regarding patient preferences for method of delivery despite concern about rising cesarean section rates. We hypothesize that the majority of pregnant women desire a vaginal birth. An anonymous survey was distributed to pregnant women assessing demographics, pregnancy history, delivery preference, and concern for outcomes. Five-hundred fifty respondents completed the survey; 43% were nulliparous. The majority preferred vaginal delivery (89.6%). Reasons included reduced recovery pain (72%), scars (68%), and bleeding (48%). Cesarean deliveries were believed to cause more maternal injuries (39%), but affect sexual function less (35%). Nulliparas were more concerned about vaginal support damage (p = .005), sexual function changes (p < or = 0.001), and need for episiotomy (p < or = .001). Despite this, 93% of nulliparas chose vaginal birth. Increased parity was associated with preference for cesarean delivery (r = 0.108, p = 0.013). Despite nulliparas' concerns about complications of vaginal delivery, the majority of pregnant women would choose vaginal birth.