The effect of rectal distension on bladder function in patients with overactive bladder.

AIMS: To investigate the effect of rectal distension on bladder sensation volumes and the number of detrusor contractions in patients with overactive bladder (OAB) symptoms. METHODS: A prospective randomized study included patients with OAB symptoms. Multichannel urodynamic studies were completed with and without rectal balloon distension. Bladder sensation volumes and detrusor contractions were compared. RESULTS: Twenty-six patients were included in the study. The mean age was 67 years and mean BMI was 28.3 kg/m(2) . Bladder sensation volumes were lower with rectal distention as follows: normal desire to void (139 ml SD, ±114 vs. 197 ml SD ±150, P = 0.01), strong desire to void (260 ml SD ±171 vs. 330 ml SD ±172, P = 0.01), and maximum cystometric capacity (326 ml SD ±183 vs. 403 ml SD ±180, P = 0.0001). There was no difference in the number of detrusor contractions or the bladder volume at which the first detrusor contraction had occurred with and without rectal distension. CONCLUSION: Rectal distention in patients with OAB symptoms significantly lowered bladder sensation volumes (normal desire, strong desire, and maximal capacity).

Vaginal paraganglioma presenting as a pelvic mass.

Paragangliomas are extra-adrenal neuroendocrine neoplasms derived from neural crest precursors. These tumors rarely arise from the female genital tract. Vaginal paragangliomas are extremely rare. We describe a case of vaginal paraganglioma managed with minimally invasive surgical techniques.

Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.

OBJECTIVE: To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. METHODS: We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. RESULTS: Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. CONCLUSION: Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. LEVEL OF EVIDENCE: III.

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.

Robotic appendectomy in gynaecological surgery: technique and pathological findings.

BACKGROUND: We evaluated the feasibility, safety and pathological findings of incidental robotic appendectomy in patients undergoing robotic gynaecological surgery. METHODS: Retrospective analysis of 107 consecutive cases of robotic appendectomy done in conjunction with other robotic gynaecological procedures between May 2004 and January 2007. RESULTS: All appendectomies were performed robotically in conjunction with other robotic procedures. Mean time for appendectomy was 3.4 min. No perioperative complications related to appendectomy were encountered. Among 90 patients with no gynaecological malignancy, 57 patients reported chronic pelvic pain preoperatively and 21 (37%) of them had an abnormal appendiceal pathology as compared to only 5 (15%) of the 33 patients with no pelvic pain (OR. 3.2; 95% CI, 1.1-9.7, p = 0.032). Of seven patients with ovarian malignancy, three (42%) had appendicular metastasis. CONCLUSION: Incidental robotic appendectomy can be performed safely without the need for switching to conventional laparoscopy. It should be considered in patients undergoing robotic pelvic surgery for pelvic pain and ovarian malignancy.

The efficacy of viewing an educational video as a method for the acquisition of basic laparoscopic suturing skills.

STUDY OBJECTIVE: To estimate the efficacy of viewing an educational video in the acquisition of laparoscopic suturing skills. DESIGN: A prospective observational study (Canadian Task Force classification II-2). SETTING: Tertiary care academic medical institution. SUBJECTS: Twelve candidates interviewing for the female pelvic medicine and reconstructive surgery fellowship position at our institution. INTERVENTIONS: Candidates were evaluated in the laparoscopy laboratory before and after watching a 6-minute educational video on the basic principles of laparoscopic suturing. Each candidate evaluation included the following tasks: (1) introduction of a needle through a trocar (timed in seconds); (2) load and position a needle for suturing with a laparoscopic needle holder (evaluated by number of movements); (3) running continuous suture with 2 passes (timed in seconds); (4) intracorporeal knot tying with 2 throws (timed in seconds); and (5) extracorporeal knot tying with 2 knots (timed in seconds). MEASUREMENTS AND MAIN RESULTS: Wilcoxon signed rank test was used for the statistical comparison of the candidates' performance before and after viewing the video. After viewing the teaching video, the total median time to perform all timed tasks improved by 20% (115.5 seconds, p = .009). Significant improvement occurred in the median time of introducing the needle through a trocar, continuous suturing, and extracorporeal knot tying (p = .02, p = .01, and p = .003, respectively). CONCLUSION: The use of an educational video appears to be an effective method for the acquisition of basic laparoscopic suturing skills.

Is transobturator tape as effective as tension-free vaginal tape in patients with borderline maximum urethral closure pressure?

INTRODUCTION: The purpose of this study was to compare transobturator tape (MONARC) with tension-free vaginal tape in patients with borderline low maximum urethral closure pressure. STUDY DESIGN: Historical cohort analysis of 3-month outcomes in 145 subjects (MONARC = 85; tension-free vaginal tape = 60). A cut-off point of 42 cm H2O for preoperative maximum urethral closure pressure was identified as predictor of success in the entire cohort. The cohort was stratified by sling type and analyzed. Outcome variables included urodynamic stress incontinence, urethral pressure profiles, subjective stress incontinence symptoms, and complications. RESULTS: The relative risk of postoperative urodynamic stress incontinence 3 months after surgery in patients with a preoperative maximum urethral closure pressure of 42 cm or less H2O was 5.89 (1.02 to 33.90, 95% confidence interval) when we compared MONARC with tension-free vaginal tape. Subjects in the MONARC and tension-free vaginal tape groups did not differ significantly in baseline characteristics. We defined subjects as failures if they demonstrated postoperative objective stress incontinence on multichannel urodynamic testing. CONCLUSION: In subjects with maximum urethral closure pressure of 42 cm or less H2O, the MONARC was nearly 6 times more likely to fail than tension-free vaginal tape at 3 months after surgery. Long-term follow-up and randomized controlled trials are needed.

Sirenomelia in a monoamniotic twin: a case report.

BACKGROUND: Sirenomelia is a rare congenital malformation characterized by fusion of the lower extremities and is associated with renal agenesis and absent bladder. Oligohydramnios usually occurs early in pregnancy. CASE: A 21-year-old primigravida with a twin gestation was diagnosed with sirenomelia in 1 of the twins at 18 weeks; they were delivered at 34 weeks. The infant was in perfect respiratory condition, lived for 5 days and died of nonpulmonary causes. CONCLUSION: Absence of oligohydramnios in monoamniotic twins allows free movement of the fetus in utero, facilitates the visualization of fetal organs on ultrasound and aids early prenatal diagnosis. It also delays the death of the sirenomelia infant due to the improved respiratory condition.