Perioperative course and medium-term outcome of the transobturator and infracoccygeal hammock for posthysterectomy vaginal vault prolapse.

OBJECTIVE: To describe the perioperative course and medium-term anatomic and functional outcomes of the transobturator-infracoccygeal hammock for posthysterectomy vaginal vault prolapse repair. METHODS: A prospective consecutive series of 52 women with a stage 2 vaginal vault prolapse or higher that occurred after total hysterectomy who underwent surgery between 2003 and 2007. Principal outcome measures were anatomic cure (stage 1 or lower) and impact on quality of life measured using the pelvic floor distress inventory (PFDI) and pelvic floor impact self-reported questionnaire (PFIQ). Anatomical results were analyzed using chi(2) and Fisher exact tests, and PFDI and PFIQ scores were analyzed using the Wilcoxon test. RESULTS: With a median follow-up of 36months, the anatomic cure rate was 96%. Significant improvements were noted in POPQ-S scores after surgery (P<0.05). Stress urinary incontinence was cured in 73% of patients and improved in 15% of patients. The PFDI and PFIQ scores were improved (P<0.05). One mesh extrusion was observed. The rates of mesh contraction and new cases of dyspareunia were 31% and 13%, respectively. CONCLUSION: The transvaginal mesh hammock represents a useful treatment for recurrent and major vaginal vault prolapse, and has few complications.

Laparoscopic hysterectomy of large uteri with uterine artery coagulation at its origin.

BACKGROUND: To argue the usefulness for performing total laparoscopic hysterectomy with primary uterine artery coagulation at its origin for a series of women presenting with an enlarged benign uterus. METHOD: Eighteen women having undergone the procedure consecutively during a period of 17 months were studied retrospectively. The inclusion criteria were an enlarged benign uterus weighing more than 280 g, managed by total laparoscopic hysterectomy with primary uterine artery coagulation at its origin. RESULTS: Patient median values (range) for age, body mass index, and parity were respectively 47.5 years (range, 38 to 53), 25 kg/m2 (range, 19.3 to 34.9), and 2 (range, 0 to 3). The median value for uterine weight (range) was 540 g (range, 280 to 1,015), and the median duration for the surgical procedure was 185 minutes (range, 90 to 260), the longest procedures being due to associated deep endometriosis resection and extensive adhesions. The duration of the intervention was not significantly correlated with uterine size (correlation coefficient r=-0.15, P=0.56), and no intra- or postoperative complications were recorded. CONCLUSION: The selective coagulation of the uterine artery at its origin is a reproducible technique that allows total laparoscopic hysterectomy in enlarged uteri. This procedure avoids unexpected intraoperative hemorrhage requiring conversion to the abdominal route and provides optimal protection for the ureter.

Pregnant noncommunicating rudimentary uterine horn with placenta percreta.

BACKGROUND: To report a placenta percreta in a 7-week gestational rudimentary noncommunicating uterine horn pregnancy. METHODS: A 28-year-old woman with no complaints presented with a rudimentary uterine horn pregnancy at 7-weeks gestation. The diagnosis was suspected by ultrasonography and diagnosed by laparoscopy. Laparoscopic excision of the rudimentary uterine horn and ipsilateral salpingectomy were performed, as well as biopsy of several peritoneal endometriosis lesions. RESULTS: A 7-week gestation pregnancy with placenta percreta was identified in the rudimentary uterine horn. No communication was found with the right unicornuate uterus. Endometriosis was confirmed. Clinical outcome was favorable. CONCLUSION: Placenta percreta may occur in rudimentary uterine horn pregnancies, but accidents may be avoided by an early diagnosis and surgical management. However, in young women who desire pregnancy, planned laparoscopic resection of a rudimentary uterine horn revealed accidentally should be discussed.