Review of sustainable practices for the gynecology operating room.

PURPOSE OF REVIEW: Climate change has immediate impacts on women's health. Hospitals and operating rooms are large contributors to greenhouse gas (GHG) emissions and waste. This article will review current green initiatives designed to minimize environmental impact in the operating room and highlight areas for future improvement. RECENT FINDINGS: From a materials perspective, reusable goods result in less GHG emissions while being just as efficacious, well tolerated, and easy to use. Materials should be opened judiciously, only as necessary. Processing regulated medical waste produces greater GHG emissions, so waste should be properly sorted, and items which are not biohazard waste should be processed separately. Choosing appropriate anesthesia and utilizing an 'off' setting, in which operating rooms are shut down when not in use, can also drastically decrease the environmental impact of surgery. Further research is needed to determine effective implementation in hospitals. SUMMARY: This article summarizes current attempts to make operating rooms more sustainable. Many practices result in a decreased carbon footprint and cost savings without adversely affecting patient outcomes. Gynecologic surgeons and the hospitals in which they practice need to focus on implementing these changes in a timely fashion.

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.

Perioperative management for gynecologic minimally invasive surgery during the COVID-19 pandemic.

PURPOSE OF REVIEW: This article will review current guidelines regarding surgical protocols for elective and nonelective surgeries during the severe acute respiratory syndrome coronavirus 2 pandemic. RECENT FINDINGS: Perioperative management for surgical patients should be modified to promote the safety and wellbeing of patients and caregivers amidst the COVID-19 pandemic. COVID-19 testing should be performed preoperatively with subsequent preprocedure quarantine. Nonemergent or nonlife-threatening surgery should be postponed for COVID-19 positive patients. The consensus of surgical societies is to use a laparoscopic surgical approach for COVID-19 positive patients when appropriate and to avoid port venting at the end of procedures. For COVID-19 positive patients requiring an emergent procedure, the use of personal protective equipment is strongly recommended. SUMMARY: After over a year of the COVID-19 pandemic, effective protocols and precautions have been established to decrease the morbidity and mortality of patients undergoing surgery and to promote the safety of healthcare personnel. Continued investigations are necessary as cases of new, possibly more virulent, strains of the virus arise.

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.

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.

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.

Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy.

OBJECTIVE: To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol. METHODS: A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015. RESULTS: Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization. CONCLUSION: Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.