Effect of age in women undergoing laparoscopic sacrocolpopexy: A retrospective study.

OBJECTIVE: To determine whether elderly women (≥65 years) have an increased risk of complications and lower success when undergoing laparoscopic sacrocolpopexy (LSC) compared with younger women (<65 years). METHODS: This was a retrospective study of all LSC procedures performed from August 2014 to February 2021 by a single urogynecologic surgeon in an academic affiliated hospital system. Charts were identified through procedure codes. Patient demographics, clinical, surgical, and postoperative data were collected. The primary outcome of this study was to compare complications associated with LSC, including intraoperative and postoperative complications. Secondary outcomes included subjective, objective, and composite success. RESULTS: In total, 312 participants met the criteria. The mean age of the group who were younger than 65 years was 55.7 years (±6.5) and of the group aged 65 years or older was 69.3 years (±3.5). Racial demographics revealed no differences between the two groups. Patients aged 65 years or older had a statistically significant lower body mass index (calculated as weight in kilograms divided by the square of height in meters), a higher rate of hypertension, smaller genital hiatus, and a larger anterior vaginal wall prolapse compared with the younger cohort. They also less often underwent a posterior repair. No statistically significant differences were found with regards to intraoperative and postoperative complications, including 30-day re-admission, between the two age groups. Both groups had high anatomic success rates, with no significant difference (<65 = 96.3%; ≥65 = 98.4%; P = 0.326). Those aged younger than 65 years compared with those aged 65 years or older had lower subjective success that was not significantly different (<65 = 62.8%; ≥65 = 71.0; P = 0.134). Composite success was noted to reach the threshold of a statistically significant difference in the group aged younger than 65 years compared with those aged 65 years or older (60.1% vs 71.0%; P = 0.0499). CONCLUSION: In this study, elderly patients did not have increased intraoperative and postoperative complications after undergoing LSC. Similar rates of anatomic and subjective success were also found with younger patients having a lower composite success. Proper candidates for LSC should not be excluded based upon age.

Comparison of Postoperative Complications Between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To compare postoperative complications of laparoscopic myomectomy (LM) with total laparoscopic hysterectomy (TLH). A secondary outcome examined whether complications differ by age. DESIGN: A retrospective cohort study. SETTING: A multicenter academic healthcare system. PATIENTS: Individuals > 18 years old undergoing LM from 2011 to 2021 or TLH for benign indications from 2020 to 2021. INTERVENTIONS: LM or TLH. MEASUREMENTS AND MAIN RESULTS: There were 1178 patients in the LM group and 1304 in the TLH group. Patients who underwent LM were younger, more often premenopausal, nonsmokers, with lower body mass index, lower preoperative hemoglobin, larger uterine size, and lower American Society of Anesthesiologists class. LM had longer operative times (154.1 ± 74.5 vs 145.9 ± 70.5 min, p <.0001), higher use of intraoperative hemostatic agents (25% vs 9.1%, p <.0001), and higher estimated blood loss (222.7 ± 313.0 vs 87.4 ± 145.9 mL, p <.0001) than TLH. Postoperatively, LM was associated with fewer surgical site infections (3.1% vs 5.8%, p <.0001), readmissions within 30 days (2.0% vs 5.6%, p <.0001), or emergency department visits within 90 days (10.9% vs 14.4%, p = .008). LM were more likely to be admitted 24 hours postoperatively (5.9% vs 3.4%, p = .0023) or receive a blood transfusion within 30 days (4.0% vs 1.0%, p <.0001). Variables associated with increased risk of postoperative complications were tobacco use, American Society of Anesthesiologists class > 3, preoperative anemia, estimated blood loss ≥ 150 mL, and specimen weight > 250 g. Logistic regression demonstrated that operative time ≥185 minutes was most strongly associated with 24-hour admission postoperatively (odds ratio [OR] = 12.95; 95% confidence interval [CI], 3.71-45.27). In individuals ≤ 37 years of age, the LM group was less likely than the TLH group to experience surgical site infection (OR, 0.30; 95% CI, 0.14-0.62) or present to the emergency department (OR, 0.40; 95% CI, 0.26-0.63). CONCLUSION: In this large cohort of patients, both LM and TLH had low rates of postoperative complications, but the complications differed for each approach. In appropriate surgical candidates, either approach may be offered based upon patients' goals.

Dexamethasone administration to improve patient recovery in ambulatory vaginal reconstructive surgery: a randomized prospective trial.

INTRODUCTION AND HYPOTHESIS: Dexamethasone is a potent glucocorticoid that may improve quality of recovery (QoR). We hypothesized that standard administration of dexamethasone at induction may improve QoR compared to placebo in subjects undergoing ambulatory vaginal reconstructive surgeries. METHODS: This was a randomized prospective clinical trial on subjects scheduled for ambulatory vaginal reconstructive surgery for prolapse and/or urinary incontinence. Intervention arm subjects were administered dexamethasone and the control group, a placebo (normal saline). Timing of administration, anesthesia medications, postoperative pain medications, and antiemetics were standardized. Primary outcome was difference in QoR (QoR-40) scores 24-48 h after surgery. Power analysis estimated that 27 subjects were required in each group to detect a difference in QoR-40 scores with 80% power and an alpha of 0.05. RESULTS: Fifty-one subjects were enrolled and randomized. 4 withdrew, 1 was excluded, and 46 were analyzed. For the primary outcome, there was no difference in the QoR-40 between the dexamethasone and placebo group (--13.5 vs -19.6, p=0.24). Postoperative nausea vomiting intensity scores were not different (8.33 vs 9.09, p=1). Pain scores were similar in the two groups (6.0 vs 4.7, p=0.12). Although not statistically significant, surgical satisfaction at 6 weeks was better with dexamethasone (23.5 vs 26.9, p=0.09). CONCLUSION: Based on this study, a single dose of dexamethasone at the time of induction prior to ambulatory vaginal reconstructive surgery was not associated with improved QoR. Standardized anesthesia protocols may play a role in postoperative nausea, pain control, and thereby QoR in patients undergoing ambulatory vaginal reconstructive surgeries.

Suprapubic-assisted transurethral excision of eroded transvaginal cerclage suture.

AIM OF THE VIDEO/INTRODUCTION: The aim was to demonstrate our minimally invasive technique for excision of eroded transvaginal cervical cerclage suture through the bladder mucosa using a suprapubic-assisted transurethral approach. Transvaginal cervical cerclage is a common treatment for cervical insufficiency in pregnancy. Complications such as erosion are rare, as the duration of treatment is typically several months, with cerclage placement in the second trimester and complete removal prior to the onset of labor. Retained suture can lead to erosion through the vaginal epithelium and into other organs, as seen in our case. Our technique offers a minimally invasive approach to the excision of eroded transvaginal cervical cerclage suture through the bladder mucosa. METHODS: A narrated, stepwise video demonstration for removal of eroded cervical cerclage through bladder epithelium with suprapubic-assisted transurethral technique in a single patient was carried out. Key strategies for a successful outcome include: use of a Carter-Thomason device for suprapubic assistance in lieu of suprapubic trocar or suprapubic incision, use of rigid biopsy forceps for improved traction on the eroded suture, performing a methylene blue test for evaluation of vesicovaginal fistula after excision procedure. RESULTS: At her 2-week postoperative evaluation, the patient reported resolution of all symptoms. The Carter-Thomason incision was well healed, and postoperative urinalysis was negative for hematuria. CONCLUSIONS: A suprapubic-assisted transurethral approach can be used as a minimally invasive technique for excision of eroded transvaginal cervical cerclage suture through the bladder mucosa.

Clinical presentation and treatment of Macroplastique® urethral exposures: a retrospective case series.

INTRODUCTION AND HYPOTHESIS: Manufacturers of Macroplastique® for urethral bulking have not previously reported exposures as potential complications. This study was aimed at identifying presenting symptoms, management, and outcomes in patients experiencing urethral or bladder exposures. METHODS: A retrospective case series from 2010 to 2019 was performed in an academic affiliated hospital system. Participants were 18-89 years old and received Macroplastique® urethral bulking for treatment of stress urinary incontinence. Charts were identified through diagnosis and procedure codes relating to injections of urethral bulking agents and foreign bodies in the bladder or urethra. Factors evaluated were patient history and presenting symptoms, diagnostic evaluation, treatment, and outcomes using frequency tables for categorical values and statistical distribution with median and interquartile ranges (IQR) for continuous variables. RESULTS: After review of 1,269 charts, 580 cases met the inclusion criteria and 14 Macroplastique® urethral exposures were identified. The median age at first presentation was 73.5 years (IQR57.5-79.7 years) with 48 months (IQR 22-78 months) as the median time to first presentation after last Macroplastique® injection. The median number of injection sessions was 2 (IQR 1-2.75 sessions) with a medium volume of 4.5 ml (IQR 2.75-9.0 ml). Presenting symptoms included urge incontinence (64.3%), stress urinary incontinence (57.1%), recurrent urinary tract infection (42.9%), urinary urgency (28.9%), urinary frequency (28.9%), urinary retention (14.3%), and interrupted flow (7.1%). Macroplastique® urethral exposures were extracted in 10 patients using blunt, sharp, or electrocautery excision. No complications after excision were identified and improvement in urinary symptoms was observed. CONCLUSION: Urethral bulking with Macroplastique® can lead to symptomatic urethral exposures.

Lógica difusa: metodología cuantitativa útil para determinar el consenso entre expertos de ciencias estomatológicas / Fuzzy logic: a useful quantitative methodology to determine consensus among dental science experts

RESUMEN La lógica difusa trata de copiar la forma en que los humanos toman decisiones. Específicamente en el área médica, se utiliza desde hace varios años en estudios aplicados a áreas como: ingeniería biomédica, sistemas expertos, modelos epidemiológicos y sistemas diagnósticos. Se confeccionó un cuestionario para medir la calidad de vida relacionada con la salud oral en adolescentes cubanos; se utilizó la lógica difusa en el proceso de validación por expertos, mediante el software PROCESA_CE (2013). En el nivel de concordancia de los expertos se rechazó la hipótesis nula de que no existe comunidad de preferencia entre ellos, para un nivel de significación de 0,01; esto garantizó, con un 99% de confiabilidad, que es posible hacer valoraciones a partir del consenso de estos expertos. Además, se corroboró la existencia de un consenso de 5 en todos los ítems.

ABSTRACT Fuzzy logic tries to copy the way humans make decisions. It has been used for several years, specifically in the medical field, in studies applied to areas such as biomedical engineering, expert systems, epidemiological models and diagnostic systems. A questionnaire was prepared to measure the quality of life related to oral health in Cuban adolescents; Fuzzy logic was used in the validation process based on expert criteria, using the PROCESA_CE (2013) software. According to expert agreements, the null hypothesis that there is no community of preference among them was rejected, for a significance level of 0.01; this guaranteed, with 99% reliability, that it is possible to make assessments based on their consensuses. In addition, the existence of a consensus of five in all items was corroborated.

Laparoscopic excision and re-attachment of sacrocolpopexy mesh.

INTRODUCTION AND HYPOTHESIS: Two cases are described and surgical techniques for recurrent pelvic organ prolapse after minimally invasive sacrocolpopexy are demonstrated at an academic affiliated hospital in patients with recurrent pelvic organ prolapse after minimally invasive sacrocolpopexy. METHODS: A laparoscopic approach was taken for surgical intervention, with excision of prior detached vaginal mesh and re-attachment of new sacrocolpopexy mesh. RESULTS: Two patients presented with recurrent pelvic organ prolapse after failed surgical treatment. The first case is a 68-year-old vaginal multipara with recurrent pelvic organ prolapse status post laparoscopic supracervical hysterectomy, sacrocolpopexy, and mid-urethral sling performed at an outside institution. Preoperative physical examination revealed stage 3 prolapse. Mesh was loosely attached to the cervix. After surgical correction, postoperative physical examination revealed stage 1 prolapse at the 6-week postoperative visit. The second case is a 62-year old vaginal multipara with recurrent pelvic organ prolapse status post-total laparoscopic hysterectomy and sacrocolpopexy at an outside institution. Preoperative physical examination revealed stage 2 prolapse. The mesh was loosely attached to the vagina. After surgical correction, postoperative physical examination revealed stage 0 prolapse at the 6-week postoperative visit. Both patients reported improvement in symptoms and overall quality of life. CONCLUSIONS: Surgical management of recurrent pelvic organ prolapse after failed initial sacrocolpopexy procedure can be safely accomplished laparoscopically through identification of points of mesh detachment, anatomical landmarks, removal of the prior vaginal portion of the mesh, and attachment of a new surgical mesh to either the sacrum or the sacral portion of the mesh.

Comparison of Methods to Identify Stress Urinary Incontinence in Women With Pelvic Organ Prolapse.

OBJECTIVE: The aim of the study was to compare which test is most sensitive in identifying stress urinary incontinence (SUI) in women with pelvic organ prolapse using urodynamics (UDS) as the criterion standard: cough stress test (CST) or pyridium pad test. METHODS: This was a prospective study of women with pelvic organ prolapse stage II or greater who desired surgical management for prolapse. Each patient underwent preoperative urinary testing: UDS, CST, and a 24-hour pyridium pad test. RESULTS: A total of 84 patients were analyzed. Using UDS as the criterion standard, both the CST and the pyridium pad test showed a fair agreement with UDS outcomes (κ = 0.27 for both tests). There was no statistically significant difference between the CST and the pyridium pad test, with estimated sensitivities of 34.4% versus 40.6% (P = 0.791), specificities of 90.4% versus 84.6% (P = 0.508). The pyridium pad test was found to have a statistically significant difference in identifying the subjective complaint of SUI (38.6%, P = 0.003) compared with other tests. Patients with occult incontinence were identified 42.5%, 17.5%, and 10% of the time during UDS, CST, and pyridium pad testing, respectively. CONCLUSION: Our data suggest that the sensitivities of the CST and pyridium pad test for stress incontinence and occult stress incontinence in patients with pelvic organ prolapse are low when compared with UDS as the criterion standard. Urodynamics has an important role in preoperative identification of occult SUI.

Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence.

ABSTRACT: Historically, our health care system has been based on a fee-for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a paradigm in which health care providers are incentivized to provide cost-effective, coordinated, value-based care in an effort to control costs and ensure high-quality care for all patients. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was created and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development.

Optimal timing of a second postoperative voiding trial in women with incomplete bladder emptying after vaginal reconstructive surgery: a randomized trial.

BACKGROUND: Rates of postoperative incomplete bladder emptying vary significantly after pelvic reconstructive surgery. With enhanced recovery protocols the paradigm is shifting towards same-day discharge and the rates of incomplete bladder emptying are expected to increase. The optimal length of time for postoperative catheter drainage has not been clearly established. There are no current studies that assess the optimal timing of a repeat voiding trial in women who have unsuccessful same day voiding trials. OBJECTIVE: This study aimed to compare the outcomes of a second voiding trial performed 2-4 days (earlier group) vs 7 days (later group) postoperatively in women with incomplete bladder emptying after vaginal prolapse surgery. Secondary aims included postoperative urinary tract infection rates, total days with a catheter, and patient-reported catheter bother between groups. STUDY DESIGN: Across 2 sites, women undergoing multicompartment vaginal repair were enrolled. Within 6 hours postoperatively, subjects had an active retrograde voiding trial. Those who passed this voiding trial exited the study; those who had persistent incomplete bladder emptying (postvoid residual >100 mL) had a transurethral indwelling catheter placed and were randomized to return for an earlier (postoperative day 2-4) vs later (postoperative day 7) follow-up office voiding trial. Subjects were followed for 6 weeks after surgery. The primary outcome was the rate of unsuccessful repeat office voiding trial. Secondary outcomes included rates of urinary tract infection, total days with a catheter, and subjective catheter bother. A power calculation based on a projected 31% difference, a power of 0.8, and an alpha of 0.05 revealed that 30 subjects were needed in each group. RESULTS: A total of 102 subjects were enrolled; 38 exited on postoperative day 0, leaving 64 subjects for randomization (4 of whom withdrew after randomization). A comparison of data revealed that randomization was effective, with no differences between the earlier and later groups in terms of demographic data or surgical procedures. Using an intention-to-treat analysis, women in the earlier group were more likely to be unsuccessful in their follow-up office voiding trial (23.3%) than the later group (3.3%), with a risk difference of 20% (95% confidence interval, 3.56-36.44) and a relative risk of 7.00 (95% confidence interval, 0.92-53.47; P=.02). A number-needed-to-treat calculation found that for every 5 patients using a catheter for 7 days postoperatively, 1 case of persistent postoperative incomplete bladder emptying was prevented. Rates of catheter bother did not differ between groups at the time of the follow-up office voiding trial or at 6 weeks (P=.09 and P=.20, respectively). Urinary tract infection rates were higher in the earlier group but did not reach statistical significance (23% vs 7%, P=.07). Regression analysis revealed that subjects who required additional pain medication refills were 9.6 times (95% confidence interval, 1.24-73.77) more likely to have persistent incomplete bladder emptying after the follow-up office voiding trial. CONCLUSION: Women with incomplete bladder emptying after multicompartment prolapse repair had a 7-fold higher risk of an unsuccessful repeat office voiding trial if performed within 4 days of surgery than when performed within 7 days of surgery. In addition, requiring additional prescriptions for analgesia increased the risk of an unsuccessful follow-up office voiding trial.

Extraperitoneal Uterosacral Ligament Hysteropexy: A Novel Treatment for Apical Compartment Prolapse.

OBJECTIVE: To treat mild-to-moderate apical compartment prolapse while preserving the uterus, our extraperitoneal uterosacral ligament hysteropexy repair technique was developed. Hysterectomy for prolapse accounted for 13% of all benign hysterectomies, which is the third most common reason.1 Although concomitant hysterectomy risks at time of prolapse surgery are not well defined, risks associated with hysterectomy have been well described in the literature. Additionally, it is well known that anterior compartment prolapse often has an apical component.2 Benefits of hysteropexy in prolapse surgery consistently cited in the literature include reduced surgical time, blood loss, and morbidity.3 A study by Frick et al, reported more than 60% of women would decline a concomitant hysterectomy if offered an equally efficacious surgical option.4 Our primary aim was to achieve anatomical success as defined as apical POP-Q less than or equal to Stage 1, resolution of subjective bulge and no reoperation for recurrent prolapse. METHODS: We performed a retrospective case series of extraperitoneal uterosacral ligament hysteropexy (EPUSLH) procedures from 2017 to 2019. RESULTS: In our case series, the objective cure rate (POP-Q apical prolapse stage ≤1) and the subjective cure rate at 5 months follow up was 100%, refer to Table 1. The mean length lost in total vaginal length compared to baseline was 0.5 cm, refer to Table 2. Mean surgical time for EPUSLH with combined procedures was 110 minutes. The mean EBL was 101 mL. CONCLUSION: EPUSLH demonstrated good short-term success with a low rate of complications in this small cohort. Being a tertiary referral center with many patients traveling long distances or internationally has limited follow-up. Although larger numbers and long-term follow-up are needed to better understand the success of this procedure, the early results are encouraging that this technique could be a simple alternative hysteropexy method.

Anesthetics' role in postoperative urinary retention after pelvic organ prolapse surgery with concomitant midurethral slings: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: Spinal anesthesia can be a potential risk factor for postoperative urinary retention (POUR). Our objective was to compare POUR rates for outpatient vaginal pelvic floor surgeries when using spinal versus general anesthesia. Our hypothesis was that spinal anesthesia would have higher POUR rates compared with general anesthesia. METHODS: This was a randomized clinical trial on subjects undergoing outpatient pelvic organ prolapse (POP) surgery with a concomitant midurethral sling (MUS). Subjects were discharged home the same day as surgery. Subjects were excluded if they had a preoperative post-void residual > 150 ml, they were < 40 years of age, surgery was < 1 h, or they had contraindications to spinal or general anesthesia. A standardized voiding trial was performed. The primary aim was to compare POUR rates between anesthesia groups. A power analysis estimated 28 subjects were required per group to detect a 37% difference with 80% power and an alpha of 0.05. RESULTS: The trial was registered at ClinicalTrials.gov on July 15, 2015. Sixty-one subjects were enrolled between June 22, 2015, and December 31, 2017. Three were excluded, leaving 29 in each group. Groups were similar in demographics. For the primary outcome, there was a 14.3% difference in POUR rates between spinal and general anesthesia, which did not reach statistical significance based on our power calculation (p = 0.2516). CONCLUSIONS: Based on this study, there is not an increased rate of POUR with the use of spinal anesthesia for POP surgery with MUS. However, since there was a trend toward higher rates of POUR in the spinal group, it is possible that a larger powered study design would be able to detect a statistically significant difference between the groups. Based on these findings, if surgical patients would benefit from spinal anesthesia, the risk of urinary retention should not be considered a reason to not utilize this form of anesthesia. CLINICAL TRIAL REGISTRATION: Does spinal anesthesia for prolapse surgery with concomitant sling lead to an increase in urinary retention compared to general anesthesia? https://clinicaltrials.gov/ct2/show/NCT02547155?term=laura+martin&rank=3 (NCT02547155).

Does spinal anesthesia lead to postoperative urinary retention in same-day urogynecology surgery? A retrospective review.

INTRODUCTION AND HYPOTHESIS: Spinal anesthesia has been reported to be a risk factor for postoperative urinary retention (POUR) in various surgical specialties. We hypothesized that spinal anesthesia was a risk factor for POUR after outpatient vaginal surgery for pelvic organ prolapse (POP). METHODS: This was a retrospective review of an urogynecology database for all outpatient POP vaginal surgeries performed in 2014 to evaluate the risk of POUR after general versus spinal anesthesia. A standardized voiding trial was performed by backfilling the bladder with 300 ml of saline. A successful trial was achieved if the patient voided two-thirds of the total volume instilled, confirmed by bladder ultrasound. Our primary outcome was to compare POUR requiring discharge with a Foley catheter between spinal and general anesthesia. Multivariate logistic regression was performed for variables with significance at p < 0.1 at the bivariate level. RESULTS: A total of 177 procedures were included, 126 with general and 51 with spinal anesthesia. The overall POUR rate was 48.9%. Type of anesthesia was not a risk factor for POUR. Multivariate logistic regression demonstrated that age < 55 years (adjusted odds ratio [OR] 3.73; 95% confidence interval [CI], 1.31-11.7), diabetes (adjusted OR 4.18, 95% CI 1.04-21.67), and having a cystocele ≥ stage 2 (adjusted OR 4.23, 95% CI 1.89-10) were risk factors for developing POUR. CONCLUSIONS: Acute urinary retention after outpatient vaginal pelvic floor surgery can vary by procedure, but overall is 48.9%. Spinal anesthesia does not contribute to POUR, but rates are higher in those women that are younger than 55 years of age, have a cystocele ≥ stage 2 preoperatively, and a history of diabetes.

Pelvic floor muscle weakness: a risk factor for anterior vaginal wall prolapse recurrence.

INTRODUCTION AND HYPOTHESIS: Native tissue vaginal repairs are associated with relatively high levels of recurrence. Systematic reviews have noted that preoperative pelvic floor muscle strength was associated with increased risk of recurrence in the short term. METHODS: This is a retrospective review of patients who underwent a primary reconstructive surgery for anterior compartment vaginal prolapse between 2001 and 2015. Patients were divided into "absent," "weak" and "good" preoperative PFM strength (aPFM, wPFM and gPFM, respectively) based on a modified Oxford scale. Failure rates were determined by a composite of subjective and objective anatomic outcomes. Subjects who underwent re-operations or procedures for recurrent prolapse of the anterior compartment were considered failures. A p value < 0.05 was considered statistically significant. RESULTS: Two hundred ninety-nine patients were included. The aPFM (n = 36), wPFM (n = 115) and gPFM (n = 148) groups had similar descriptive statistics, except subjects in the aPFM and wPFM groups were significantly older than the gPFM group (p = 0.008). All groups underwent similar reconstructive surgeries. Average length of follow-up of 143.9 weeks (41 to 717 weeks) was similar among the three groups (p = 0.472). For the primary outcome of composite failure, aPFM had significantly more anterior vaginal wall recurrences than both the wPFM and gPFM groups, 13.89% vs. 3.48% and 4.05%, respectively (p = 0.033). CONCLUSIONS: Patients with preoperative absent pelvic floor muscle strength (nonfunctioning PFM) had a significantly higher anterior vaginal wall recurrence rate than those with weak or good pelvic floor muscle strength.

Advanced uterovaginal prolapse: is vaginal hysterectomy with McCall culdoplasty as effective as in lesser degrees of prolapse?

INTRODUCTION AND HYPOTHESIS: There is a paucity of data on the success of vaginal surgery for severe prolapse. The authors hypothesized that the success rates of total vaginal hysterectomy (TVH) with McCall culdoplasty in women with advanced pelvic organ prolapse (POP) and in women with less severe POP are similar. METHODS: This was a retrospective review of women undergoing TVH with McCall culdoplasty from 2005 to 2014. Advanced POP was defined as exteriorized uterovaginal prolapse with Pelvic Organ Prolapse Quantification (POP-Q) point C, Ba or Bp ≥50% of the total vaginal length. The primary aim was to compare surgical success of TVH with McCall culdoplasty for the repair of advanced POP and less severe POP at ≥1 year. RESULTS: A total of 311 women were included, 38 with advanced POP and 273 with less severe POP. Women with advanced POP were older (71.6 vs. 61.8 years, respectively; p < 0.0001), but there were no significant differences in the length of follow-up (102.5 vs. 117 weeks, p = 0.2378), success rates (76.3% vs. 68.5%, p = 0.3553) or reoperation rates (2.6% vs. 4%, p > 0.9999) between women with advanced POP and less severe POP, respectively. There was a higher failure rate in the anterior compartment in those with advanced POP (18.4% vs. 6.2%, p = 0.0168), but not in the apical or posterior compartment. CONCLUSIONS: TVH with McCall culdoplasty is equally effective for the treatment of advanced uterovaginal prolapse as for the treatment of less severe POP. Surgeons should consider this traditional surgery for their patients even if they have high-stage uterovaginal prolapse.

Transvaginal Repair of Complex Rectovaginal Fistulas Using the Porcine Urinary Bladder Matrix as an Augmenting Graft.

BACKGROUND: After the US Food and Drug Administration issued a safety warning concerning vaginal mesh implants in 2008, their use in correction of pelvic floor defects have decreased in the United States (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm). However, we are still treating patients who have had complications associated with their use, rectovaginal fistulas (RVFs) being one of them. Rectovaginal fistulas are considered complex if greater than 2.5 cm, recurrent, associated with inflammatory bowel disease, or if they are proximal in location. Various surgical techniques have been described for treating RVFs. Interposition grafts such as Martius, gracilis, omental J flaps, and rectus abdominis flaps have been used extensively in correcting RVFs (Am J Gastroenterol 2014;109(8):1141-1157). However, these techniques may increase morbidity or have poor cosmesis. Pelvic surgeons have chronicled the use of biologic grafts for fistula repair. Of the various biologic grafts in use, there have been no reports describing the use of porcine urinary bladder matrix (UBM) for fistula repair. We report on 2 cases of large, complex RVFs secondary to mesh erosion, which were effectively treated with transvaginal repair using the UBM. CASES: An 80-year-old woman was referred by the colorectal service to our urogynecology service with complaints of rectal bleeding and vaginal spotting secondary to mesh erosion. Surgical history included hysterectomy with mesh augmented posterior repair with synthetic midurethral sling placement in 2002. Examination revealed a 3-cm mesh exposure located in the middle third of the posterior vaginal wall. On rectovaginal examination, a 3-cm full-thickness RVF with through-and-through mesh erosion was noted between the rectum and vagina.A 65-year-old woman presented to our service with complaints of passage of fecal material through the vagina. Surgical history was significant for hysterectomy in 1988 and prolapse repair with anterior and posterior vaginal mesh in 2009. Subsequently in 2011, she had part of the mesh removed because of exposure. Vaginal examination revealed mesh exposure at the right sulcus of the anterior wall consistent with evidence of prior sling and another mesh exposure on the posterior vaginal wall. Rectovaginal examination revealed palpable mesh in the rectovaginal septum with a 3-cm large and complex fistula. Both of our patients underwent transvaginal excision of mesh, RVF repair, and posterior repair with augmentation with UBM. At 6- and 10-month follow-up, they reported complete resolution of their symptoms with no fistula noted on physical examination. CONCLUSIONS: Typically, traditional repair with use of muscular advancement flaps is performed for complex RVF closures. Recently, however, various biologic agents have been successfully used to augment RVF repair. In our cases, the use of UBM led to successful follow-up at 6 to 8 months. Despite existing literature, there remains a void in the depth of knowledge regarding the UBM grafts. Larger studies utilizing it for repair of RVFs are warranted to further understand the success and effectiveness of the UBM grafts for RVF repair.

Resolution of Rectal Prolapse by Vaginal Reconstruction.

BACKGROUND: Rectal prolapse is a disorder of the pelvic floor in which the layers of the rectal mucosa protrude outward through the anus. Surgical repair is the mainstay of treatment. Options include intra-abdominal procedures such as rectopexy and perineal procedures such as the Delorme and Altemeier perineal rectosigmoidectomy. Rectal and vaginal prolapse can often coexist. However, to our knowledge, there are no reported cases of rectal prolapse resolved by the repair of a compressive enterocele abutting the anterior rectal wall through a vaginal approach alone. We present a novel case of rectal prolapse that resolved by correction of the vaginal defect. CASE: A 53-year-old female with prior history of abdominal hysterectomy, presented to the urogynecology clinic with complaints of vaginal bulge, urge urinary incontinence, and rectal bulge on straining with no fecal incontinence for several years. On physical examination, she was found to have stage 2 anterior, posterior, and apical vaginal prolapse and reducible rectal prolapse. Colorectal surgery (CRS) evaluation was requested, which revealed minimal anterior mucosal prolapse on Valsalva with no full-thickness prolapse. Magnetic resonance imaging (MRI) defecogram was performed, which demonstrated a large rectocele, enterocele, and small bowel prolapsing between the rectum and vagina during the evacuation phase, with no rectal prolapse. The decision to proceed with vaginal prolapse surgery without concomitant rectal prolapse repair was made, as the patient had no fecal incontinence, and the degree of rectal prolapse was minimal. On the day of surgery, which was 2 months later, she presented with a 2-cm anterior rectal prolapse with no incontinence. Colorectal surgery was consulted again, but unavailable. After counseling, the patient wished to proceed with her planned surgery. It was felt that correcting the anterior rectocele and enterocele, thereby eliminating the descent of the bowel on the anterior rectal wall, might cause resolution of the rectal prolapse. She then underwent a sacrospinous ligament fixation with mesh through an anterior vaginal approach, enterocele repair, Moschcowitz culdoplasty, and posterior colporraphy. She had an uneventful postoperative course and noted resolution of both vaginal and rectal prolapse. At 54 weeks, she continues without any complaints of rectal prolapse, which was confirmed on physical examination. CONCLUSIONS: Usually, the choice of surgical approach is tailored to each individual based on anatomy, age, comorbidity, and patient factors. Correcting both vaginal and rectal prolapse at the same time with a minimally invasive approach is an advantage to the patient. Restoring the apical, anterior, and posterior vaginal wall anatomy and an enterocele repair through the vaginal route caused resolution of the rectal prolapse. Further research is required as to whether rectal prolapse caused by anterior rectal compression needs an additional procedure or repair of the vaginal prolapse and enterocele alone will suffice.

Intraoperative Cystoscopic Evaluation of Ureteral Patency: A Randomized Controlled Trial.

OBJECTIVE: To compare different modalities to aid in the evaluation of intraoperative ureteral patency on cystoscopy in the postindigo carmine era. METHODS: In a randomized controlled trial, participants undergoing pelvic surgery were randomized into one of four groups: saline distention (control), 10% dextrose distention, oral phenazopyridine, or intravenous sodium fluorescein. Our primary outcome was visibility of the ureteral jets. Secondary outcomes included surgeon satisfaction; adverse reactions including allergies, urinary tract infections, urinary retention, cystoscopy times, and ureteral obstruction; and delayed diagnosis. Participants were followed for 6 weeks. A sample size of 176 participants was planned to demonstrate a 30% difference in the visibility scale. All analyses were performed in an intention-to-treat fashion. RESULTS: From February 25, 2015, through August 2015, 176 participants were enrolled; 174 completed the trial, and two did not undergo intervention. Forty-four participants were included in the phenazopyridine, dextrose, saline, and sodium fluorescein groups. Sodium fluorescein and 10% dextrose resulted in significantly improved visibility and satisfaction when compared with the control group (P<.001 and P=.004, respectively). Dextrose provided the highest satisfaction and phenazopyridine provided lowest, but visibility was not statistically different between the two groups (P=.101). Three ureteral obstructions were identified intraoperatively and none in the postoperative period. Mean total cystoscopy time varied between 4.0 and 4.8 minutes and postoperative urinary retention rate was 50% across all groups. Overall urinary tract infection rate was 24.1%, which was similar between interventions. There were no related adverse events. CONCLUSION: Compared with the control, 10% dextrose and sodium fluorescein resulted in improved visibility and provided significantly more satisfaction in the evaluation for ureteral patency with no considerable increase in operative time or morbidity. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02476448.

Apical sling: an approach to posthysterectomy vault prolapse.

INTRODUCTION AND HYPOTHESIS: This video demonstrates a transvaginal technique for vaginal vault suspension using an apical sling suspended from the sacrospinous ligaments. METHODS: This was a retrospective review of apical sling procedures performed from July 2013 to November 2014. The technique is started by marking the vaginal apex. A posterior dissection is performed and the sacrospinous ligaments are identified after dissection into the pararectal space. A 10-cm piece of monofilament, inelastic polypropylene tape is attached to the underside of the vaginal apex. Polypropylene sutures are placed into the sacrospinous ligament and threaded though the lateral edges of the apical sling and tied down, restoring apical support. Finally, the vaginal epithelium is closed. RESULTS: A total of 67 women underwent an apical sling procedure with 70 % (47/67) completing 6 months follow-up. The subjective cure rate ("cured" or "greatly improved") was 78.7 % and the objective cure rate (anatomical success, defined as apical prolapse stage ≤1) was 100 % (47 patients). CONCLUSIONS: Our apical sling sacrospinous ligament fixation approach is a unique, minimal mesh approach using a tape commonly used for midurethral slings to suspend the vaginal apex. We achieved high anatomical success and patient satisfaction.