Retained Tampon Fragment as an Unusual Cause of Vesicovaginal Fistula.

BACKGROUND: Vesicovaginal fistula (VVF) is an uncommon cause of urinary incontinence (UI). Iatrogenic etiologies, especially abdominal hysterectomy, are most common; however, a minority of VVFs are caused by retained foreign bodies. Objects associated with VVF include intrauterine devices, gauze, pessaries, bottle caps, and sexual aids, but retained tampons or other menstrual products have not been commonly reported. CASE: We present the case of a 53-year-old woman, gravida 0, with no prior pelvic surgery, with 2 months of intermittent UI and hematuria. Although initial diagnostic test results were negative, cystoscopy and vaginoscopy eventually confirmed the diagnosis of VVF associated with a retained foreign body. In the operating room, all debris was removed using vaginoscopy, and the VVF was repaired using a modified Latzko technique. At the patient's 9-week follow-up appointment, she was found to have complete healing of the VVF and resolution of associated symptoms. CONCLUSION: This is a case of VVF secondary to a retained tampon fragment. In addition to this uncommon etiology, our patient's presenting symptoms were atypical, leading to a delay in diagnosis and treatment for which vaginoscopy was critical.

Racial Disparities in Sacral Neuromodulation for Idiopathic Fecal Incontinence.

IMPORTANCE: Sacral neuromodulation (SNM) is an effective treatment for fecal incontinence (FI). Previous studies found that Black women undergo SNM for urinary incontinence less than White women, but there is less known about racial disparities for FI. OBJECTIVE: This study assessed differences in Black and White patients' FI treatment; SNM counseling was the primary outcome. STUDY DESIGN: This was a retrospective cohort study of adult non-Hispanic Black and White patients who received FI treatment at an academic institution from 2011 to 2021. Medical records were queried for treatments, testing, and treating specialties for a 2:1 age-matched cohort of White:Black patients. RESULTS: Four hundred forty-seven women were included: 149 Black women and 298 age-matched White women. A total of 24.4% (109) of patients had documented SNM counseling, significantly fewer in Black patients (14.8% vs 29.2%, P < 0.001). A total of 5.1% (23) of patients received SNM, less frequent in Black patients (2.7% vs 6.4%, P = 0.003). Among patients with SNM counseling, there was no difference between cohorts. Black patients were less likely to be referred for physical therapy (59.7% vs 77.2%, P < 0.001), sphincter imaging (0.7% vs 5.7%, P = 0.011), and defecography (8.1% vs 17.1%, P = 0.009). Different specialties managed the 2 cohorts. Black patients were less likely to see urogynecology and colorectal surgery (21.5% vs 34.6%, P = 0.004; 9.4% vs 15.4%, P = 0.077). Patients seen by these surgeons were more likely to discuss SNM (48.6% vs 8.5%, P < 0.001). CONCLUSIONS: There were differences between Black and White patients' FI treatment, including counseling about SNM. Multidisciplinary work is needed to provide equitable education for this life-altering condition.

Referral and Prescription Patterns for Female Patients With Urinary Incontinence.

IMPORTANCE: Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them. OBJECTIVES: To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system. STUDY DESIGN: Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates. RESULTS: In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48). CONCLUSION: Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.

Why Patients Fall Through the Cracks: Assessment of Patients' Overactive Bladder Treatment.

Objective: Despite an established treatment algorithm for overactive bladder (OAB), it is unclear how many patients proceed through each step. Our objective was to evaluate the percentage of patients receiving each step of care and identify reasons why patients did not receive certain treatments. Methods: This was a retrospective cohort study with cross-sectional survey of new OAB patients. The medical record was queried for relevant patient characteristics and documentation of conservative, medical, and third-line therapies. In the survey, patients were asked about current bladder symptoms and reasons why they did not use certain treatments. Descriptive statistics were used for analysis. Results: One hundred eleven patients met the inclusion criteria; the most common diagnosis was mixed incontinence (40%, n = 45). The median number of visits for OAB was 2 (range 1-8). On retrospective analysis, 64% (71) of patients had documented attempts at conservative therapy. Seventy-six percent (84) of patients attempted medical therapy, and only 11% (12) progressed to any third-line therapy. Fifty-nine percent (64) of eligible patients responded to the survey. Fifty-three percent (34) of respondents reported persistent moderate to very severe bother due to bladder symptoms. Thirty percent to fifty percent of patients who did not attempt one or more of the three levels of OAB therapy reported that they were never offered that treatment option. Conclusions: Many patients do not progress to the next steps in OAB therapy despite failure of more conservative treatments. Barriers to care included limited follow-up and education about other therapy options. A formalized institutional care pathway may lead to improved OAB treatment.

Differences in fatigability of muscles involved in fecal continence: Potential clinical ramifications.

INTRODUCTION: Fatigue of the anal sphincter complex has been demonstrated using high-resolution anorectal manometry (HRAM). However, the fatigability of individual muscles such as the external anal sphincter (EAS) and puborectalis muscles (PRM) has not been described. Vaginal manometry has been used to study contractile activity of the PRM. By applying both modalities, we attempted to differentiate the fatigability between the PRM and the EAS under different exercise conditions. METHODS: We studied two groups: group 1, 12 healthy women (21 ± 2.7 years) with HRAM and group 2, 10 healthy (20 ± 3 years) women with vaginal manometry. All subjects performed 40 repetitive contractions with and without an intra-anal resistive load. In group 1, areas under the curve (AUC) of the anal canal high-pressure zone (HPZ) including the caudal and rostral halves were compared. In group 2, the maximum and mean pressures of the vaginal HPZ were compared. RESULTS: The AUC decreased significantly only after repetitive contractions against a resistive load (462 ± 129 vs. 390 ± 131 mmHg-cm, p = 0.02), indicating fatigue. The caudal half (EAS) decreased significantly after contractions against a load (288 ± 75 vs. 239 ± 82 mmHg-cm, p = 0.02), while the rostral half (PRM) did not. The vaginal pressures (PRM) also decreased only after repetitive contractions against a load (maximum pressures, 358 ± 171 vs. 239 ± 109 mmHg, p = 0.02). CONCLUSIONS: The EAS and PRM both exhibit fatigue with contractions only against a resistive load. These findings may guide the development of appropriate exercise regimens to target specific muscles involved in fecal continence.

Perioperative outcomes following pelvic floor reconstruction in women with hereditary disorders of connective tissue: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesized that patients would have increased incidence and severity of perioperative complications up to 6 weeks after surgeries for POP/SUI. Secondary objectives were to compare pre- and post-operative pelvic floor symptoms and anatomical support as well as pelvic floor disorder recurrence. METHODS: In this multi-center retrospective cohort study, we identified patients with HDCTs by patient history and ICD-9 codes over an 11-year period. Controls without HDCTs were matched 2:1 to the primary POP or SUI procedure and surgeon. Demographic characteristics, perioperative pelvic floor information and complications were collected. A sample size of 65 HDCT patients and 130 controls was calculated to detect a 20% difference in complications with 80% power and alpha of 0.05. RESULTS: We identified 59 HDCT patients and 118 controls. Of the women with HDCTs, 49% had Ehlers-Danlos, 22% joint hypermobility syndrome, 15% Marfan syndrome, and 14% had others. Compared with controls, HDCT patients had more total perioperative complications (46% vs 22%, p = 0.002); an age-adjusted relative risk of complications was 1.4 (CI 0.7-2.6). HDCT patients had more Clavien-Dindo grades I and II complications (p = 0.02, 0.03) and more hospital readmissions (14% vs 3%, p = 0.01) than controls. There was no difference in the incidence of specific complications nor was there a difference in recurrence of POP (10%) or SUI (11%) between groups. CONCLUSIONS: Patients with HDCTs had more Clavien-Dindo grade I and II complications following pelvic floor reconstructive surgery and more readmissions.

Predictors for Pelvic Organ Prolapse Recurrence After Sacrocolpopexy: A Matched Case-Control Study.

OBJECTIVE: This study aimed to identify risk factors for prolapse recurrence after sacrocolpopexy. METHODS: This was a retrospective chart review with cross-sectional follow-up survey of 709 patients who underwent sacrocolpopexy of any modality from 2004 to 2014. Cases were defined as those with a composite failure, defined as having subjective bulge symptoms, retreatment, or anatomic prolapse (≥stage 2 prolapse on the Pelvic Organ Prolapse Quantification system). Controls were patients without composite failure. The cases and controls were matched by surgeon and by date of surgery in a 1:4 ratio. RESULTS: We identified 153 cases and matched them to 487 controls. The overall incidence of prolapse recurrence was 21.6% (95% confidence interval [CI], 18.2%-24.1%). Of the recurrence cases, 34 (22.2%) underwent surgical retreatment; the most common surgical retreatment was a posterior colporrhaphy (n = 16 [47.1%]). On multivariable logistic regression, a preoperative genital hiatus size ≥4 cm (adjusted odds ratio [adjOR], 1.95; 95% CI, 1.18-3.25) and concurrent anterior colporrhaphy (adjOR, 2.11; 95% CI, 1.06-4.18) were associated with increased odds of having a composite failure. Patients who had a concurrent posterior colporrhaphy had lower odds of experiencing a failure (adjOR, 0.62; 95% CI, 0.42-0.94). CONCLUSIONS: In this large retrospective chart review of women who underwent sacrocolpopexy with a cross-sectional survey follow-up time frame of nearly 7 years, patients with a preoperative genital hiatus of 4 cm or greater and need for concurrent anterior colporrhaphy at the time of their index surgery had higher odds of prolapse recurrence. Conversely, women who underwent a concurrent posterior colporrhaphy had lower odds of a recurrence.

Long-term pelvic organ prolapse recurrence and mesh exposure following sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Large, long-term studies are needed to compare pelvic organ prolapse (POP) recurrence and mesh exposure following all modes of sacrocolpopexy (open, robotic, and laparoscopic). We hypothesized that the prevalence of recurrent POP and mesh exposure does not differ between modes of sacrocolpopexy. METHODS: This is a retrospective cohort study with a cross-sectional, prospective survey. Participants were surveyed regarding complications, retreatments, and symptoms following sacrocolpopexy. Baseline characteristics, POP recurrence, mesh exposure, and survey responses were compared. RESULTS: A total of 709 participants met the criteria. Median time from sacrocolpopexy to last follow-up for all participants was 0.5 years (2 days to 13.4 years). 15.0% experienced recurrent stage 2 or greater POP or underwent retreatment (open 11.7% [95% CI 7.8-17.2%]; robotic 21.1% [95% CI 15.6-27.9%]; laparoscopic 13.8% [95% CI 10.6-17.9%]; p = 0.03). After adjusting for baseline differences there was no significant difference among groups (p = 0.30). 5.3% experienced mesh and/or suture exposure (mesh n = 19, suture n = 10, mesh and suture n = 8) with no significant difference among groups (open 7.7% [95% CI 4.6-12.5%]; robotic 3.6% [95% CI 1.7-7.6%]; laparoscopic 4.9% [95% CI 3.1-7.7%]; p = 0.20). Median time from sacrocolpopexy to survey completion was 6.5 (1.6-13.4) years. 9.2% reported evaluation or treatment for recurrent POP (open 6.3% [95% CI 2.1-16.8%]; robotic 12.5% [95% CI 6.9-21.5%]; laparoscopic 8.5% [5.1-13.8%]; p = 0.44). 6.9% reported evaluation or treatment for mesh exposure (open 6.0% [95% CI 2.1-16.2%]; robotic 3.9% [95% CI 1.3-10.7%]; laparoscopic 8.6% [5.2-13.9%]; p = 0.38). CONCLUSIONS: Objective and patient-reported long-term prevalence of POP recurrence and mesh exposure are low following all modes of sacrocolpopexy.

Does concurrent posterior repair for an asymptomatic rectocele reduce the risk of surgical failure in patients undergoing sacrocolpopexy?

PURPOSE: To determine if a concurrent posterior repair for an asymptomatic rectocele at the time of sacrocolpopexy reduces the incidence of surgical failure. METHODS: This is a retrospective chart review with a cross-sectional follow-up survey of all patients who underwent sacrocolpopexy from 2004 to 2014. Demographic and operative data were collected from the medical record. For the cross-sectional portion, patients were contacted to obtain information on symptoms and retreatment after surgery. In this study, we included patients with an asymptomatic rectocele on examination, defined as Ap or Bp ≥ -1 on POP-Q without defecatory dysfunction, which was defined as constipation based on the Rome III criteria, dyschezia, excessive straining and/or splinting to have a bowel movement. The primary outcome was a composite score of subjective bulge symptoms or retreatment for prolapse. RESULTS: Three hundred forty-four patients met the inclusion criteria: 185 (53.8%) had a sacrocolpopexy only (SCP) and 159 (46.2%) had a concurrent posterior repair (SCP + PR). The composite failure rate was 10.2% (95% CI = 7.4-13.8%), with a 13.5% (25) failure rate in the SCP group compared with 6.3% (10) in the SCP + PR group (p = 0.03). On multivariable logistic regression, the adjusted odds of failure was 2.79 in the SCP compared with the SCP + PR group (CI 1.25-6.23; P = 0.01). The rates of de novo defecatory dysfunction following surgery were low (SCP = 5.6% vs. SCP + PR = 7.5%, p = 0.55). CONCLUSIONS: For patients with asymptomatic rectoceles, a concurrent posterior repair at the time of sacrocolpopexy reduces the odds of composite patient-centered failure without an increased rate of dyspareunia or de novo defecatory dysfunction.

A randomized controlled noninferiority trial of reduced vs routine opioid prescription after prolapse repair.

BACKGROUND: Given the accelerating opioid crisis in the United States and evidence that patients use fewer opioid tablets than prescribed, surgeons may choose to decrease prescribed quantities. The effect this may have on patient satisfaction with pain control after hospital discharge is unknown. OBJECTIVE: The primary objective of this study was to compare patient satisfaction with postoperative pain control between patients receiving a routine or reduced quantity opioid prescription after prolapse repair. Secondary objectives included a comparison of opioid-related side-effects, the number of opioid tablets used, and the number of excess tablets prescribed between these groups. STUDY DESIGN: This was a single-center, unmasked, 2-arm, randomized controlled noninferiority trial of women who underwent a prolapse repair with a planned overnight hospitalization. Patients were assigned randomly to 1 of 2 study arms: routine (28 tablets of oxycodone 5 mg) or reduced (5 tablets) prescription of opioid tablets. Patients were eligible if they were at least 18 years of age and undergoing a prolapse repair with an anticipated overnight hospital stay. Exclusion criteria included a history of chronic pain, preoperative opioid use, intolerance to study medication, or a score of ≥30 on the Pain Catastrophizing Scale. In addition to their opioid prescription, all patients received multimodal pain medications at discharge. Patients were asked to complete 6 weeks of diaries to record pain and medication use. The primary outcome (patient satisfaction) was collected as part of a postoperative survey completed at patients' routine postoperative visit 6 weeks after surgery. The sample size for noninferiority was calculated at 59 patients per group for a total of 118 patients. RESULTS: One hundred eighteen patients were assigned randomly; the primary outcome was available for 116. The majority of patients were white, postmenopausal, and nonsmokers; the mean age was 62±10.4 years. The most common surgery was a hysterectomy with native tissue repair (n=71; 60%). One hundred ten patients (93%) were satisfied with postoperative pain control. Statistical analysis constructed for noninferiority showed that the difference between the groups was <15% (93% vs 93%; P=.005). Subjects in the reduced arm reported requiring an additional opioid prescription more frequently than in the routine arm (15% vs 2%; P=.01). Patients in the routine arm used more opioid tablets than the reduced arm (median, 3 [interquartile range, 0-14] vs 1 [interquartile range, 0-3]), but overall opioid utilization was low. As such, patients in the routine arm had significantly more unused opioid tablets (median, 26 [interquartile range, 15-28] vs 4 [interquartile range, 2-5]). CONCLUSION: Patient satisfaction with pain control was noninferior in patients who received a reduced quantity of opioid tablets after prolapse repair compared with those who received a routine prescription. A large quantity of excess opioid tablets was seen in both groups. Surgeons should consider prescribing 5-10 opioid tablets after prolapse repair surgery and consider applying these findings to postoperative prescribing after other gynecologic procedures.

Pelvic Organ Prolapse Recurrence and Patient-Centered Outcomes Following Minimally Invasive Abdominal Uterosacral Ligament and Mesh-Augmented Sacrohysteropexy.

OBJECTIVES: The objective of this study was to compare outcomes after minimally invasive uterosacral ligament hysteropexy (USLH) and mesh-augmented sacrohysteropexy (MSH) for women with uterovaginal prolapse including prolapse recurrence and long-term patient satisfaction. METHODS: This was a retrospective cohort study with a cross-sectional survey component. The medical record was queried for perioperative data for patients undergoing USLH and MSH between 2004 and 2016. Pelvic organ prolapse (POP) recurrence was defined as bulge symptoms and/or retreatment with a pessary or surgery. A cross-sectional survey assessed for adverse events and used validated questionnaires to assess symptoms and improvement. RESULTS: Ninety-seven patients met the inclusion criteria: 42 MSH and 55 USLH. Mean age was 48 ± 14 years. Patients undergoing MSH were older, had more advanced POP, and were less likely to undergo concurrent procedures. There were no differences in perioperative complications between groups; 22.7% (n = 22) of patients experienced POP recurrence with 8.3% (n = 8) undergoing repeat surgery. After controlling for preoperative differences, there was no difference in POP recurrence between groups. The incidence of sacrohysteropexy mesh exposure was 7% (n = 3). Sixty-one percent (n = 59) of patients completed the survey; median follow-up time was 104 (46-164) months. Forty-one percent of respondents reported bothersome pelvic floor symptoms. Bulge symptoms were more common after MSH (41% vs 10%, P = 0.006). Ninety-three percent of all patients reported improvement after surgery, which was not different between groups. CONCLUSIONS: One in 5 patients experienced POP recurrence with fewer than 10% undergoing repeat surgery for recurrence. There does not seem to be a significant difference in the incidence of recurrence between MSH and USLH.

Patient-Centered Outcomes After Modified Vestibulectomy.

OBJECTIVE: To describe patient outcomes after modified vestibulectomy for vulvodynia. METHODS: This is a mixed-methods study of patients who had undergone modified vestibulectomy for vulvodynia at a tertiary care hospital from 2009 through 2016. Demographics, preoperative and postoperative examinations, symptoms, and treatments were obtained through retrospective review. Prospective semistructured interviews were conducted from 2018 through 2019 to address patient-reported changes in pain and sexual function. Qualitative analysis was performed using a grounded theory approach. RESULTS: Twenty-two patients underwent modified vestibulectomy from 2009 through 2016. Age ranged from 22 to 65 years and mean body mass index was 24.3±5.4. The majority of patients were premenopausal (57%), sexually active (68%), and partnered (76%). Postoperatively, data on pain improvement were retrieved on 18 patients, of which 17 (94%) reported improvement. Patients used pelvic floor physical therapy, medications, and lubricants both preoperatively and postoperatively. For the qualitative analysis, thematic saturation was achieved with 14 interviews. Of 14 participants interviewed, 13 (93%) reported improvement with pain after surgery, 11 (79%) reported satisfaction with surgery, 8 (57%) reported satisfaction with sexual function, and 11 (79%) reported recommending the surgery to others. The following lead themes were identified: vulvodynia symptoms significantly affect quality of life; there is difficulty and delay in diagnosis owing to lack of information and awareness among patients and health care providers; and surgical success and satisfaction are influenced by patient perceptions with sexual dysfunction often persisting despite vulvar pain improvement. CONCLUSION: Vulvodynia patients report improvement in pain and high overall satisfaction after modified vestibulectomy, but more variable long-term effects on sexual function.

Pelvic organ prolapse recurrence in young women undergoing vaginal and abdominal colpopexy.

INTRODUCTION AND HYPOTHESIS: While pelvic organ prolapse (POP) recurrence is believed to increase over time, outcomes of young women who undergo POP surgery are unclear. We hypothesized POP recurrence incidence among women <49 years would be higher after vaginal versus abdominal colpopexy. METHODS: This is a retrospective cohort study with a cross-sectional survey of women 18-49 years who underwent primary POP surgery from January 2003 to September 2013. Patients were identified by CPT codes for vaginal and abdominal colpopexy. POP recurrence was defined as vaginal bulge symptoms, POP retreatment (pessary or surgery) or both. Validated questionnaires were used to assess pelvic floor symptoms, patient satisfaction and improvement. RESULTS: Three hundred thirty-three women met the criteria. Mean age was 43 (+ 5.3) years; 29.1% (97) had an abdominal colpopexy and 70.9% (236) had a vaginal colpopexy. The recurrence incidence overall was 32.0% (31) in the abdominal group and 24.2% (57) in the vaginal group (p = 0.15), with a 10.3% (10) retreatment incidence in the abdominal group and 5.9% (14) in the vaginal group (p = 0.16). Forty-five percent (149) responded to the survey at a median time of 7.9 (3.1-15.2) years since surgery. The overall recurrence incidence in respondents was 13.7% (7) in the abdominal group and 15.3% (15) in the vaginal group (p = 0.80), with a retreatment incidence of 5.9% (3) in the abdominal and 5.2% (5) in the vaginal group (p = 0.85). CONCLUSIONS: One in four young women experienced subjective POP recurrence and/or retreatment, but only 5-10% underwent retreatment. There does not appear to be a difference in the incidence of recurrence between vaginal and abdominal colpopexy.

Baseline Understanding of Urinary Incontinence and Prolapse in New Urogynecology Patients.

OBJECTIVES: Investigators sought to assess whether age was related to patient understanding of pelvic floor disorders; given studies show that increased age is associated with lower health literacy. METHODS: This was a cross-sectional survey of new urogynecology patients. Enrolled participants completed a survey including demographics, history of urinary incontinence (UI) and pelvic organ prolapse symptoms and treatment, the Prolapse and Incontinence Knowledge Questionnaire (PIKQ), self-assessment of UI and prolapse knowledge, and a pelvic anatomy diagram to label. To achieve 80% power to detect a 2-point difference in PIKQ score, 33 subjects were required per age group (<65 and ≥65 years old). RESULTS: One hundred thirty-five of 160 new urogynecologic patients completed the survey (84% response rate). Thirty-seven participants were older than 65 years, and 98 were younger than 65 years. Total PIKQ scores (maximum, 24), the primary outcome, for the older and younger groups were 15.3 and 15.0, respectively (P = 0.7). The 2 groups self-rated UI and prolapse knowledge similarly, rating knowledge as excellent, very good, or good in 60% (P = 0.3) and 40% (P = 0.2) of subjects, respectively. CONCLUSIONS: Baseline patient understanding of UI and pelvic organ prolapse was low as assessed by PIKQ score and was not influenced by age.

Use of Vessel-Sealing Devices during Vaginal Hysterectomy.

STUDY OBJECTIVE: To demonstrate the proper use of vessel-sealing devices during vaginal hysterectomy. DESIGN: Educational video (Canadian Task Force classification level III). SETTING: University hospital. INTERVENTION: The video reviews the principles on the use of energy in minimally invasive surgery. We focus on how vessel-sealing devices function and the benefits of their use in difficult vaginal hysterectomy. The video explains the 2 major types of complications, inadequate vessel sealing and undesired thermal injury, and demonstrates techniques to avoid these complications. MEASUREMENTS AND MAIN RESULTS: Laboratory, intraoperative, and cadaveric recordings demonstrate proper use and the complications that may arise in the setting of improper use. CONCLUSION: Vessel-sealing devices may be a useful tool for surgeons performing vaginal hysterectomy. This video demonstrates their use and underlines the importance of understanding the principles of energy devices and their proper usage in surgery.

Perioperative adverse events in women undergoing concurrent urogynecologic and gynecologic oncology surgeries for suspected malignancy.

INTRODUCTION AND HYPOTHESIS: This study's objectives were to compare the incidence of adverse events after concurrent urogynecologic and gynecologic oncology surgery to gynecologic oncology surgery alone and to describe the frequency of modification in planned urogynecologic procedures. The authors hypothesized there would be no difference in major complications. METHODS: This was a retrospective matched cohort study of women who underwent concurrent surgery at a large tertiary care center between January 2004 and June 2017. Cohorts were matched by surgeon, surgery route, date, and final pathologic diagnosis. Perioperative data and postoperative adverse events classified by Clavien-Dindo grade were compared. RESULTS: One hundred and eight patients underwent concurrent surgeries, with 216 matched cohorts. Concurrent-case patients were more likely to be older, postmenopausal, have greater vaginal parity, have had preoperative chemotherapy, and have preoperative cardiac or pulmonary disease. There were no differences in intraoperative complications or Dindo grade ≥ 3 adverse events between groups, but there were more grade 2 adverse events in the concurrent cohort (44 vs 19%, p < 0.0001) including postoperative urinary tract infection (UTI) (26 vs 7%, p < 0.0001). Concurrent surgery remained associated with a higher incidence of grade ≥ 2 events on multivariate analysis [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2, p = 0.0004). Discharge with a urinary catheter was more frequent after concurrent cases (35 vs 2%, p < 0.0001). Planned urogynecologic procedures were modified in 10% (n = 11) of cases. CONCLUSIONS: Concurrent surgeries have an increased incidence of minor but not serious perioperative adverse events. One in ten planned urogynecologic procedures is either modified or abandoned during combined surgeries.

Route of hysterectomy during minimally invasive sacrocolpopexy does not affect postoperative outcomes.

INTRODUCTION AND HYPOTHESIS: Hysterectomy can be performed during sacrocolpopexy, but there are limited studies comparing the effect of route of hysterectomy on adverse events. We hypothesized there would be no difference in adverse events or patient-reported outcomes in women who underwent minimally invasive sacrocolpopexy with either vaginal or supracervical hysterectomy. METHODS: This was a retrospective chart review with a cross-sectional survey component sent to all consenting patients. Patients were identified by procedure code for sacrocolpopexy and hysterectomy from January 2005 to June 2016. RESULTS: Of the 161 subjects meeting the inclusion criteria, 116 underwent supracervical and 45 vaginal hysterectomy. Overall incidence of perioperative adverse events was low. Vaginal hysterectomy cases were faster (276 vs. 324 min, p < 0.001) and had higher rates of postoperative stress incontinence (22 vs. 9%, p = 0.03). Thirty-one (19%) of all subjects had recurrent prolapse; 10 (6%) underwent repeat surgery. Three (1%) subjects had a mesh exposure (no difference between groups), all treated conservatively. Ninety-six (60%) subjects responded to the survey with a median follow-up of 56 (9-134) months. Ninety-one percent (87) of respondents reported being better since surgery, and 91% (87) reported they would choose the surgery again. Twenty-eight percent (27) reported a surgery-related complication including pain, urinary and bowel symptoms; 8% (8) reported evaluation for recurrent prolapse symptoms, all treated conservatively; 4% (4) of respondents reported a mesh exposure. CONCLUSIONS: Incidence of adverse events is low and not different between patients undergoing minimally invasive sacrocolpopexy with concurrent supracervical or vaginal hysterectomy. One in three patients report pelvic floor symptoms postoperatively, but long-term satisfaction is high.

A Gartner Duct Cyst Masquerading as Anterior Vaginal Prolapse.

BACKGROUND: Gartner duct cysts are embryologic remnants of the mesonephric ducts that may present as a vaginal mass or cyst. CASE: A patient was referred for surgical management of prolapse whose bulging anterior vagina was actually a Gartner duct cyst that required excision as a result of symptoms. Preoperative magnetic resonance imaging helped confirm the diagnosis. CONCLUSION: A Gartner duct cyst may present as a vaginal cyst that, if large, may mimic pelvic organ prolapse. The diagnosis should be considered when a patient's individual prolapse compartments are inconsistent or when physical examination is suggestive of another process.