A pilot study on vaginally assisted laparoscopic sacrocolpopexy for patients with uterovaginal prolapse.

OBJECTIVES: : The primary objective of this pilot study was to compare the short-term anatomic outcomes and complication rates of vaginally assisted laparoscopic sacrocolpopexy (VALS) with those of conventional laparoscopic sacrocolpopexy (LS) in patients undergoing concurrent hysterectomy. The secondary objective was to compare operative times of the 2 different techniques. METHODS: : This is a retrospective pilot study comparing VALS-a method using transvaginal mesh attachment to the vaginal apex-to conventional LS in patients undergoing concurrent hysterectomy. RESULTS: : Forty-four women underwent VALS, and 26 women underwent LS. There was no significant difference in intraoperative complication rates (2.3% vs 3.8%, not statistically significant), postoperative complication rates (4.5% vs 0.0%, P = 0.526), mesh extrusion rates (2.3% vs 0%, not statistically significant), or postoperative pelvic organ prolapse quantification scores. The mean total operative time was 55 minutes shorter for the VALS group (215.2 [SD, 41.0] minutes) than the LS group (269.7 [SD, 55.6] minutes; P < 0.001). CONCLUSIONS: : There was no significant difference in short-term anatomic outcomes or complication rates between groups. Vaginally assisted LS was associated with significantly shorter operative times than conventional LS.

Interposition grafts for rectovaginal fistula repair in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The objective was to use an animal model to study different types of interposition grafts for rectovaginal fistula repair. METHODS: Twelve New Zealand white rabbits underwent surgical creation of a rectovaginal fistula, followed by repair. Four repair techniques were studied; three with interposition grafts and one control group without a graft. Animals were euthanized at 4-week intervals and underwent gross and histologic analysis. RESULTS: The mean rectovaginal wall thickness was greatest in the control group (5.6 mm) and thinnest in the autologous rectus fascia (4.2 mm) and porcine small intestine submucosa (5.1 mm) groups. The polypropylene graft had a mean thickness of 5.4 mm and elicited a strong, protracted inflammatory response. All fistulas were successfully closed except one porcine small intestine submucosa repair. CONCLUSIONS: There is no benefit from interposition graft use for rectovaginal fistula repair in our New Zealand white rabbit model.

Rectovaginal fistula model in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to create an animal model to study rectovaginal fistula repair. METHODS: Fourteen New Zealand white rabbits underwent surgical creation of a rectovaginal fistula. The technique was developed with a pilot study conducted on the first two animals, then standardized and performed on the remaining 12 rabbits. The standardized technique included making a defect in the rectovaginal septum using a 3-mm skin punch then splinting the defect with 6-mm tubing for 2 weeks. RESULTS: Using the standardized technique, a fistula was successfully created in all 12 rabbits ranging from 1 to 5 mm (mean = 2.8 mm, SD = 1.1). A 95% tolerance interval was calculated for the model and predicted that a successful fistula can be created ranging from 0.3 to 5.2 mm in 85% of attempts with the model. CONCLUSION: The New Zealand white rabbit is a promising animal model to study rectovaginal fistula repair.

Ureteral stents and retrograde studies: a primer for the gynecologist.

PURPOSE OF REVIEW: To review basic techniques and recent advances in endourology for the practicing gynecologist. RECENT FINDINGS: New ureteral stent designs are available to improve comfort and reduce some of the complications of indwelling ureteral stents. A large prospective study failed to show a significant benefit of prophylactic ureteral catheterization prior to major gynecological surgery to reduce the risk of ureteral injury. There is a shift in the management of some iatrogenic ureteric injuries from surgical reimplantation to more conservative endoscopic management by interventional radiologists and urologists. SUMMARY: The indications, techniques, and complications of advanced endourology techniques including the use of indwelling ureteral stents and retrograde pyelography are reviewed. Indwelling ureteral stents are used to establish and maintain patency of the ureters for many indications, including specific gynecological indications such as iatrogenic ureteral injury, ureteric fistula, extrinsic compression from tumor, and prophylactically to prevent ureteric injury. Retrograde pyelography is a very useful technique to image the renal collecting system with particular utility in patients with contraindications to intravenous contrast and to investigate suspected iatrogenic ureteral injuries.

Prophylactic Burch colposuspension at the time of abdominal sacrocolpopexy: a survey of current practice patterns.

INTRODUCTION: The purpose of this study was to determine the utilization of the prophylactic Burch procedure with abdominal sacrocolpopexy since the publication of the Colpopexy and Urinary Reduction Efforts (CARE) trial. METHODS: Using an Internet survey, 1,134 members of the American Urogynecological Society (AUGS) were contacted in May 2008 and questioned regarding their practice patterns to prevent de novo stress incontinence after sacrocolpopexy. RESULTS: Two hundred sixty-six responses were obtained for a 23% response rate. Of the 235 respondents actively performing sacrocolpopexies, 133 (57%) would not perform a prophylactic Burch colposuspension at the time of sacrocolpopexy in a woman without symptoms of stress urinary incontinence. Respondents were more likely to perform a prophylactic Burch if it had been more than 6 years since they completed residency or fellowship training. CONCLUSIONS: Prophylactic Burch colposuspension at the time of abdominal sacrocolpopexy has not been uniformly implemented into clinical practice by AUGS members since the publication of the CARE Trial.

De novo stress incontinence and pelvic muscle symptoms after transvaginal mesh repair.

OBJECTIVE: We sought to determine the rate of de novo stress incontinence, pelvic muscle symptoms, mesh exposure, visceral injury rate, and recurrent prolapse after transvaginal mesh repair. STUDY DESIGN: We conducted a retrospective review of 335 consecutive women with stage II or worse vaginal prolapse who underwent Prolift (Ethicon, Somerville, NJ) between July 7, 2005 and Jan. 31, 2008. RESULTS: In all, 71% underwent total Prolift, 20% anterior, and 8% posterior alone. Average age was 62 years and mean follow-up was 8 months. The intraoperative visceral injury rate was 6.6%, mesh exposure rate was 3.8%, and recurrent failure rate was 5.2%. The postoperative de novo stress incontinence rate was 24.3%. In this series, 18% of women had pelvic muscle symptoms postoperatively; 74% of these resolved within 6 months with conservative management. CONCLUSION: After Prolift, surgeons can expect a low rate of recurrent prolapse and mesh exposure. However, pelvic muscle dysfunction and de novo stress incontinence will be encountered postoperatively in a moderate number of women.