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).

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.

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.

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.

Perioperative Outcomes of Colpocleisis at a Single Institution: A Retrospective Cohort Study.

IMPORTANCE: There is limited literature reporting perioperative outcomes among colpocleisis types. OBJECTIVES: This study aimed to describe perioperative outcomes after colpocleisis at a single institution. STUDY DESIGN: Patients who underwent colpocleisis at our academic medical center between August 2009 and January 2019 were included. A retrospective chart review was performed. Descriptive and comparative statistics were generated. RESULTS: A total of 367 of 409 eligible cases were included. Median follow-up was 44 weeks. There were no major complications or mortalities. Le Fort and posthysterectomy colpocleises were faster than transvaginal hysterectomy (TVH) with colpocleisis (95 and 98 minutes, respectively, vs 123 minutes; P = 0.00) with decreased estimated blood loss (100 and 100 mL, respectively, vs 200 mL; P = 0.000). Urinary tract infection and postoperative incomplete bladder emptying occurred in 22.6% and 13.4% of all patients, respectively, with no difference among the colpocleisis groups (P = 0.83 and P = 0.90). Patients who underwent concomitant sling were not at increased risk of postoperative incomplete bladder emptying (14.7% for Le Fort and 17.2% for total colpocleisis). Prolapse recurred after 0 Le Fort (0%), 6 posthysterectomy (3.7%), and 0 TVH with colpocleisis procedures (0%) (P = 0.02). CONCLUSIONS: Colpocleisis is a safe procedure with a relatively low complication rate. Le Fort, posthysterectomy, and TVH with colpocleisis have similarly favorable safety profiles and very low overall recurrence rates. Concomitant TVH at the time of colpocleisis is associated with increased operative time and increased blood loss. Concomitant sling procedure at the time of colpocleisis does not increase the risk of short-term incomplete bladder emptying.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis.

IMPORTANCE: Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial. OBJECTIVE: We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective. STUDY DESIGN: We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios). RESULTS: Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications. CONCLUSIONS: Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

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 Assessment of Bladder Emptying After Female Pelvic Floor Surgery: A Randomized Controlled Trial.

IMPORTANCE: To study alternative voiding trial (VT) methods after urogynecologic surgery that may potentially decrease catheterization. OBJECTIVE: The aim of the study is to compare voiding assessment based on a minimum spontaneous voided volume of 150 mL with the standard retrograde fill (RF) approach in women after urogynecologic procedures. STUDY DESIGN: Women undergoing urogynecologic surgery were randomized to RF or spontaneous void (SV) groups. Women in the RF group had their bladders backfilled with 300 mL of saline before catheter removal, those in the SV group did not. To pass the VT, patients in the RF group were required to void 150 mL at one time within 60 minutes, and patients in the SV group had to do the same within 6 hours. The primary outcome was the VT failure rate. We also compared the false pass rate, urinary tract infections, satisfaction, and preference of VT method. RESULTS: One hundred nine women were enrolled in the study, 54 had SV and 55 underwent RF. Baseline characteristics were not significantly different other than history of prior hysterectomy. There was no significant difference in procedures between the groups. There was no difference in VT failure rate between the groups-SV (7.4%) and RF (12.7%, P = 0.39). The false pass rate was 0 in each group. Urinary tract infection rates were similar between SV (14.8%) and RF (14.5%) groups ( P = 0.34). Patient satisfaction for VT method was not significantly different. CONCLUSIONS: Spontaneous VT was not superior to retrograde void trial. Therefore, we cannot recommend one method of VT after urogynecologic surgery.CondensationVoiding assessment based on minimum SV of 150 mL is comparable with VT with RF after surgeries for prolapse and urinary incontinence.

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.

Short-Term Outcomes of Vaginal Hysterectomy at the Time of Robotic Sacrocolpopexy.

OBJECTIVE: With the introduction of robotic sacrocolpopexy (RSC) at our institution in 2008, we noted a reduction in residents' vaginal hysterectomy (VH) experience. In 2012, we made a transition to perform VH on all robotic sacrocolpopexies. Our objective was to report our short-term outcomes and adverse events. METHODS: In this case series, we evaluated women who underwent VH with concomitant RSC for stages II to IV pelvic organ prolapse between 2012 and 2017. In these cases, the vesicovaginal and rectovaginal spaces were developed transvaginally. Descriptive analysis including demographics, short-term outcomes, and adverse events are reported. RESULTS: In this group of 209 women, median (interquartile interval) duration of follow-up was 49 (26-60) weeks. The majority of the women were white (84.7%) and postmenopausal (80.9%), with a mean (SD) age of 59 (9) years. At a median follow-up time of 49 weeks, pelvic organ prolapse quantification revealed 20 patients (12.4%) with Ba or Bp greater or equal to 0 and 1.4% of patients required repeat prolapse surgery. Among 9 women (4.3%) with postoperative fever, 4 (1.9%) were treated for pelvic collection/abscess. Of 5 women (2.4%) who had venous thromboembolism, 3 (1.4%) were diagnosed with pulmonary embolism. There were 18 patients (8.6%) treated for urinary tract infection within 6 postoperative weeks. Mesh exposure was noted in 16 (7.7%) of the patients, and 11 (6.2%) required reoperation. CONCLUSIONS: Vaginal hysterectomy at the time of RSC may increase the risk of infection and mesh exposure compared with procedures without concomitant hysterectomy.

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.

Laparoscopic Colpo-Pneumo Occluder as a Vaginal Mold for Vaginal Reconstruction.

BACKGROUND: Currently, there is no commercially available soft vaginal mold designed for reconstructive surgeries for congenital vaginal anomalies. Stricter operating room regulations discourage the use of makeshift molds from foams and gloves. A colpo-pneumo-occluder balloon is designed to maintain pneumoperitoneum after colpotomy in laparoscopic hysterectomies and is approved for use in vaginal surgeries. CASE: A 17-year-old girl with a congenital transverse vaginal septum experienced recurrent obstruction and hematocolpos. We successfully used a colpo-pneumo-occluder balloon as a vaginal mold during postoperative care. Its size and design make this device ideal for use in vaginal reconstructive surgeries in adolescents. SUMMARY AND CONCLUSION: The laparoscopic colpo-pneumo-occluder, a sterile vaginal device, is appropriate to use as an adjustable, soft vaginal mold for correction of congenital and acquired vaginal anomalies.

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.

Anterior Bilateral Sacrospinous Ligament Fixation: A Safe Route for Apical Repair.

OBJECTIVES: Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. METHODS: This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. RESULTS: In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. CONCLUSIONS: Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

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.

Sling Plication for Failed Midurethral Sling Procedures: A Case Series.

OBJECTIVES: The aim of this article is to report the outcomes of sling plications performed on women who presented with persistent stress urinary incontinence after midurethral sling. METHODS: All women who underwent sling plication for persistent stress urinary incontinence after placement of either retropubic or transobturator midurethral sling were included in this case series. For plication, first, the suburethral incision was opened. After mobilization of the mesh in the midline, the sling was plicated with absorbable sutures. Descriptive data were extracted from the electronic medical record. Postoperative stress urinary incontinence was diagnosed based on patients' response to the relevant question on the urinary distress inventory and compared this outcome with respect to the original sling placement approach. RESULTS: We identified 36 women who underwent sling plication between March 2013 and November 2016: 26 (72.2%) following a retropubic and 10 (27.7%) following a transobturator sling. Median time between midurethral sling and plication procedure was 6.8 weeks (range, 2-148 weeks). Median follow-up after sling plication was 17 weeks (range, 2-104 weeks). Overall, 24 women (66.6%) reported subjective resolution of stress incontinence. Success rate for plication of retropubic slings was 20 (76.9%) of 26 and significantly higher compared with 4 (40%) of 10 for transobturator slings (P = 0.034). There were no mesh erosions or persistent urinary retention after sling plication. CONCLUSIONS: Sling shortening by plication is an effective low-risk option for the management of persistent stress urinary incontinence following a midurethral sling. This approach was found to be more successful after retropubic slings.