Treatment of Vaginal Shortening and Narrowing With Autologous Buccal Mucosa Graft Augmentation Without Vaginal Mold.

Vaginal foreshortening can occur after hysterectomy leading to inability to engage successfully in vaginal intercourse resulting in decreased quality of life. Vaginal elongation using autologous buccal mucosal graft with mold and postoperative bed rest has been reported extensively for vaginal stenosis and foreshortening, but graft without mold has never been described. A 61-year-old woman 5 years after robotic-assisted hysterectomy with foreshortened vagina and vaginal stricture sought care secondary to the inability to have sexual intercourse. Her vagina was successfully repaired with autologous buccal mucosal grafting without the use of a vaginal mold facilitating a next-day discharge and ultimately ability to resume intercourse. Vaginal shortening and narrowing after hysterectomy can be repaired using autologous buccal mucosal grafting without the need for a vaginal mold or 5 to 7 days of bed rest.

A novel approach to recurrent vaginal vault prolapse in a patient with müllerian agenesis.

BACKGROUND: Vaginal agenesis is a congenital disorder affecting 1 in 4000 to 1 in 10,000 females. Lack of normal vaginal support structures may lead these patients to develop prolapse of the distal rudimentary vagina. Presently, there is no consensus regarding the best surgical option. However, the goal of surgery is to restore normal anatomy and establish normal sexual function. CASE: We report the case of a 28-year-old woman with müllerian agenesis, diagnosed at age 19 years, who presented with complaints of dyspareunia and vaginal eversion. One year before presentation to our practice, the patient underwent an anterior and posterior repair with mesh and a transobturator sling. After careful evaluation, the patient underwent excision of mesh and a second procedure to elongate and suspend her vagina. Her vaginal length was extended from 4 to 8 cm. CONCLUSIONS: Prolapse of the neovagina in müllerian agenesis is a rare event; it can occur after nonsurgical or surgical treatments. Although there have been reported cases of abdominal or laparoscopic sacrocolpopexy to correct vaginal vault prolapse in these patients, there is a scarcity of information addressing the vault suspension in cases lacking healthy vaginal tissue. Our case shows how successful anatomical functional correction can be achieved with a simpler technique using an allograft to achieve a normal vaginal length in combination with a sacrocolpopexy.

Surgical treatment of persistent vaginal granulation tissue using CO(2) laser vaporization under colposcopic and laparoscopic guidance.

INTRODUCTION: There have been many reports in the literature on vaginal mesh erosion as a complication of pelvic floor reconstructive surgery. Several reports describe successful surgical excision of the exposed mesh as a resolution. However, in rare cases of mesh erosion, poor surgical outcomes and multiple resection failures have been reported. We describe an innovative surgical approach to persistent vaginal mesh erosion using CO(2) laser vaporization under colposcopic and laparoscopic guidance. CASE DESCRIPTION: A 58-y-old postmenopausal woman first presented with a 3-y history of vaginal discharge and spotting after undergoing a Mentor ObTape transobturator sling (Mentor Corp, Santa Barbara, CA), for the treatment of stress urinary incontinence. Despite surgical removal of the mesh and multiple attempts at cauterization of persistent granulation tissue, her symptoms persisted. DISCUSSION: Using a CO(2) laser under colposcopic and laparoscopic guidance, we were able to safely expose and remove the remaining portion of retained mesh. To our knowledge, this is the first report describing CO(2) laser vaporization as a surgical approach for the successful treatment of recurrent mesh erosion.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery. METHODS: The charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial. RESULTS: Forty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3-9.8). CONCLUSIONS: A higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Characteristics of physicians who choose fellowship training in obstetrics and gynecology.

INTRODUCTION: : To determine the attributes and motivation of physicians who pursue fellowship training in the subspecialties of Obstetrics and Gynecology (Ob/Gyn). METHODS: : We surveyed current fellows and recent graduates from the ABOG recognized subspecialties in Ob/Gyn. Demographics and reasons for pursuing fellowship training were obtained. Significant differences between and among groups were determined using the Mann-Whitney U test and Pearson χ test. RESULTS: : Forty-two percent of those sent a survey responded. The majority were between ages 30 to 35 (65.7%), female (60.5%), married (74.5%), and White (68.8%). Over 55% in each subspecialty cited interest in subject area as the primary reason for choosing their fellowship. CONCLUSION: : Interest in subject remains the primary motivation for the majority of physicians choosing subspecialty fellowship training in Ob/Gyn. There is considerably more variation regarding what physicians' secondary motivation is and these reasons appear to vary according to the particular subspecialty.

Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs.

INTRODUCTION AND HYPOTHESIS: Our objective was to establish the overall graft erosion rate in a synthetic graft-augmented repair 3 months postoperatively. METHODS: A retrospective chart review was performed on a cohort of subjects who underwent mesh-augmented vaginal reconstructive surgery during an 18-month period. We defined graft erosion as exposure of any mesh upon visual inspection of the entire vagina at the 3-month postoperative visit. Statistical tests performed to evaluate proportional differences were the Pearson chi square and Fisher exact tests. Independent t test was performed to compare mean differences. RESULTS: A total of 124 grafts were implanted. The overall erosion rate was 11.3%. There was a significantly lower erosion rate when using "commercial kits" vs. our traditional repairs (1.4% [one out of 69] vs. 23.6% [13 out of 55]; p < 0.001). CONCLUSIONS: Our study demonstrates a significantly lower erosion rate when using a "commercial kit" to repair pelvic organ prolapse compared to our traditional synthetic graft-augmented repair.

Anatomic relationships of the "top-down" mid-urethral sling.

OBJECTIVE: To determine the anatomic relationships between the "top-down" mid-urethral sling (MUS) and pelvic structures. STUDY DESIGN: Placement of the sling needle delivery device was performed in 10 cadaveric hemi-pelves. The distances between major structures in the pelvis and the needle delivery device were recorded. RESULTS: The mean distances are as follows: mid pubis 1.71 (+/- 0.25) cm, bladder neck 1.66 (+/- 0.37) cm, urethral orifice 3.96 (+/- 0.52) cm, obturator foramen 3.90 (+/- 0.43) cm, inferior epigastric vessels 3.50 (+/- 0.62) cm, accessory obturator vessels 3.53 (+/- 0.36) cm and external iliac vein 4.02 (+/- 0.42) cm. CONCLUSION: Major pelvic structures are in close proximity to the needle delivery device in a top-down mid-urethral sling.

Urinary tract injury during hysterectomy based on universal cystoscopy.

OBJECTIVE: To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease. METHODS: This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease. RESULTS: Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation. CONCLUSION: Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury. LEVEL OF EVIDENCE: III.

The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy.

OBJECTIVE: To evaluate the incidence of urinary tract injury due to hysterectomy for benign disease. STUDY DESIGN: Patients were enrolled prospectively from 3 sites. All patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign disease underwent diagnostic cystourethroscopy. RESULTS: Four hundred seventy-one patients participated. Ninety-six percent (24/25) of urinary tract injuries were detected intraoperatively. There were 8 cases of ureteral injury (1.7%) and 17 cases of bladder injury (3.6%). Ureteral injury was associated with concurrent prolapse surgery (7.3% vs 1.2%; P = .025). Bladder injury was associated with concurrent anti-incontinence procedures (12.5% vs 3.1%; P = .049). Abdominal hysterectomy was associated with a higher incidence of ureteral injury (2.2% vs 1.2%) but this was not significant. Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy. CONCLUSION: The incidence of urinary tract injury during hysterectomy is 4.8%. Surgery for prolapse or incontinence increases the risk. Routine use of cystoscopy during hysterectomy should be considered.

Levator contraction strength and genital hiatus as risk factors for recurrent pelvic organ prolapse.

OBJECTIVE: To correlate levator ani contraction strength and genital hiatus measurements with surgical failure in prolapse. STUDY DESIGN: This retrospective study involved chart review for documentation of levator contraction strength, genital hiatus measurement, and recurrent pelvic floor disorders in women who underwent surgery for prolapse. RESULTS: The recurrent prolapse rate was 34.6%. Median follow-up interval was 5 months. Diminished levator strength was associated with recurrent prolapse (35.8% versus 0%; P = .017). A genital hiatus 5 cm or greater was associated with recurrent prolapse (44.2% vs 27.8%; P = .034). Inability to contract the levator ani was associated with urinary incontinence (35.1% vs 18.8%; P = .023). Increasing levator contraction strength was associated with a decreased reoperation rate for pelvic floor disorders, whereas genital hiatus correlated best with recurrent prolapse. CONCLUSION: Diminished levator ani contraction strength and a widened genital hiatus correlate with an increase in surgical failures in the early postoperative period. These tools are useful for counseling a patient concerning surgery for prolapse.

Sinus formation after insertion of a silicone-coated suburethral sling.

We report the case of a 65-year-old woman who developed a sinus tract after a suburethral synthetic silicone mesh sling placement. After removal of the sling material with debridement and reconstruction of the suburethral tissue, fascia lata harvest with a sling to abdominal rectus fascia was performed. Silicone mesh may erode to form a sinus tract if used as suburethral sling material.

The anatomy of midurethral slings and dynamics of neurovascular injury.

The aim of this study was to investigate the course of midurethral slings using tension-free vaginal tape. The TVT procedure was performed on six fresh pelves, measurements were obtained, and the structures were cross-referenced in 16 embalmed pelves. The midurethral sling enters the suburethral tissue 2.2-3 cm caudad to the internal urethral meatus, pierces the paraurethral musculature and vascular plexus, and exits 2+/-0.5 cm from the midline lateral to the point of insertion of the arcus tendineus fasciae pelvis. On the pubic tubercle the sling is 4+/-0.5 cm, 4+/-1 cm and 6+/-1 cm from the accessory obturator, the inferior epigastric and the external iliac vessels, respectively. The critical angle of error resulting in the external iliac vessel injury is 7-15 degrees. A current knowledge of pelvic anatomy may help the surgeon avoid the neural and vascular structures that are in the path of the sling.

Medium-term follow-up of transvaginal suburethral slings: variance in outcome success using two different evaluation methods.

OBJECTIVES: To compare Groutz-Blaivas' Simplified Urinary Incontinence Outcome Score (SUIOS) with retrospective chart review for medium-term evaluation of transvaginal suburethral slings. METHODS: A total of 127 consecutive women underwent transvaginal suburethral sling surgery using In-fast bone screw technology, with a fascia lata graft, from April 1997 to September 1998 (30-month follow-up), performed by a single method. Retrospective evaluation of the patients' office charts was compared with the outcome data determined by the previously validated SUIOS. RESULTS: Of the 107 available patients, 65 (61%) responded. When evaluating the patients' charts retrospectively, we obtained a complete cure of urinary stress incontinence in 59 (91%), improvement in 3 (4.5%), and complete failure in 3 (4.5%) of the 65 women. Of the 65 patients, 9 (13.5%) reported urge incontinence. The overall urge de novo rate was 9% (6 of 65). On the basis of the SUIOS, 24 (37%) were cured, 22 (34%) had good results, and 10 (15%) of the 65 women had a fair response. By SUIOS, 21 (60%) of 35 patients with mixed incontinence continued having urge incontinence episodes postoperatively compared with 16 (53%) of 30 patients without documented preoperative urge incontinence who developed de novo urge incontinence postoperatively (P <0.05). CONCLUSIONS: Despite extensive preoperative counseling, patients perceive any kind of postoperative urinary incontinence as a poor outcome. However, we, as physicians, regard success as cure of the stress component when the surgical intervention is concerned. A validated simplified urinary incontinence score represents a more objective account of the outcome.