Traumatic labial bladder diverticulum and vesico-vulvar fistula.

BACKGROUND: Injuries to the female urinary tract are rare after pelvic trauma. The sequelae of these injuries are often delayed, and misdiagnosis is common. CASE: A woman with a history of pelvic trauma presented with a labial mass that was found to be a large bladder diverticulum. In addition, she was ultimately diagnosed with a traumatic vesico-vulvar fistula that was successfully repaired using a novel surgical technique. CONCLUSIONS: In patients with a history of pelvic trauma and genitourinary symptoms, it is important to consider injury to the female bladder and urethra. Further, successful repair of vesico-vulvar fistulas can be accomplished with cystoscopic fulguration and dissection of the supraurethral fistulous tract.

Routine use of preoperative cystourethroscopy on the surgical management of urinary incontinence and pelvic organ prolapse.

OBJECTIVES: To determine the impact of routine preoperative cystourethroscopy on the surgical management of urinary incontinence and pelvic organ prolapse. METHODS: Retrospective review of consecutive women undergoing surgery for urinary incontinence and/or pelvic organ prolapse at a tertiary referral urogynecology center to determine whether the routine use of preoperative cystourethroscopy changed the surgical management. Patients with other indications for cystourethroscopy were excluded. RESULTS: A total of 283 consecutive charts were reviewed of which 235 met inclusion criteria. Five patients accounted for 6 abnormal findings on preoperative cystourethroscopic examination including 2 bladder calculi, 2 lesions suspicious for neoplasm, and 2 cases of absent unilateral ureteric efflux. In only one case (0.5%) was the surgical plan altered. CONCLUSION: The routine use of preoperative cystourethroscopy in low-risk patients being prepared for surgery for urinary incontinence and pelvic prolapse is not required when no other indications for cystourethroscopy exist.

Prospective evaluation of surgical outcomes of robot-assisted sacrocolpopexy and sacrocervicopexy for the management of apical pelvic support defects.

OBJECTIVE: To evaluate outcomes of robot-assisted sacrocolpopexy (RSCP) and sacrocervicopexy (RCSP). METHODS: We conducted a prospective study of women undergoing RSCP or RCSP between June 2008 and January 2010. RESULTS: A total of 85 cases (48 RSCP and 37 supracervical hysterectomy with concomitant RCSP) were performed: 33% (28/85) for stage II, 54% (46/85) for stage III, and 13% (11/85) for stage IV pelvic organ prolapse (POP). Six weeks postoperatively, 96% (80/83) had stage 0, 2.4% (2/83) had stage I, and 1.2% (1/83) had stage II POP (P < 0.001). Six months postoperatively, 77% (24/31) had stage 0, 6.5% (2/31) had stage I, and 16% (5/31) had stage II POP (P < 0.001). Mean surgical time, estimated blood loss, and length of hospital stay was 194 ± 54 minutes, 49 ± 48 cm, and 1.6 ± 0.72 days, respectively. There were 2 cases of mesh erosion (2.3%), both in the RSCP group. CONCLUSIONS: RSCP and RCSP are effective, efficient, and safe procedures.

Surgical management of apical pelvic support defects: the impact of robotic technology.

INTRODUCTION AND HYPOTHESIS: Our aim was to determine what effect access to robotic technology had on our approach to managing apical pelvic support defects. METHODS: This was a retrospective chart review of 187 pelvic floor reconstructive surgeries performed for the 18 months prior to (time period 1: January 2007 to July 2008) and following (time period 2: July 2009 to December 2009) the introduction of the robot. Chi-square was used to compare percentages, and analysis of variance (ANOVA) was used to compare demographic data among groups. RESULTS: Overall, 187 procedures were performed for apical prolapse during the study period: 61 in time period 1 and 126 in time period 2. Following the introduction of robotic technology, a significant change from vaginal to abdominal reconstruction occurred. Uterosacral ligament suspension declined from 67 % to 22 % (p < 0.0001), whereas sacrocolpopexy increased from 25 % (15/61) to 66 % (83/126) (p < 0.0001). The rate of abdominal sacrocolpopexy, however, declined from 25 % (15/61) to 2 % (2/126) over the two time periods (p < 0.0001). CONCLUSION: The introduction of robotic technology significantly affected the surgical procedure and mode of surgical access for repair of apical pelvic support defects.

Variance in abdominal wall anatomy and port placement in women undergoing robotic gynecologic surgery.

STUDY OBJECTIVES: To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Seventy-eight women undergoing robotic surgery between May 2008 and March 2009. INTERVENTION: Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement. MEASUREMENTS AND MAIN RESULTS: Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p <.001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p <.001). Mean upper abdominal length correlated with BMI (p <.001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p <.001). CONCLUSIONS: Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.

Anal incontinence in women with and those without pelvic floor disorders.

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.

Anal sphincter injury in women with pelvic floor disorders.

OBJECTIVE: 1) To estimate the rate of anal incontinence and anal sphincter injury in a group of women with pelvic floor disorders; 2) to evaluate the relationship between anal incontinence and anal sphincter injury as demonstrated by endoanal ultrasonography; 3) to explore any associations between operative vaginal delivery and anal sphincter injury in this population. METHODS: A cohort of 100 women with stage II or greater pelvic organ prolapse and/or urinary incontinence completed the Rockwood-Thompson Fecal Incontinence Severity Index Questionnaire (FISI). Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification system. Multichannel cystometry and endoanal ultrasonography were performed. Categorical data were compared using the chi(2) statistic. The FISI scores were correlated with degree of anal sphincter injury using the Pearson correlation coefficient (r). RESULTS: Fifteen women with pelvic organ prolapse only, 28 with urinary incontinence only, and 57 with both were evaluated. Mean age (+/- standard deviation) and body mass index were 57.1 +/- 13.2 years and 29.8 +/- 6.8 kg/m(2), respectively. Median parity was 3. Fifty-four percent of those studied had anal incontinence, and 52% had anal sphincter defects. Anal incontinence was significantly associated with sphincter injury (odds ratio 36.4, 95% confidence interval 12-114, P <.001). The FISI scores were positively correlated with increasing degrees of anal sphincter disruption (r = 0.81, P <.001). A history of operative vaginal delivery was significantly associated with anal sphincter injury (P =.023). CONCLUSION: Anal incontinence and anal sphincter injury are common in women with other pelvic floor disorders and are significantly related. Operative vaginal delivery may contribute to unrecognized anal sphincter trauma in this population. LEVEL OF EVIDENCE: III

Thermal balloon endometrial ablation for management of acute uterine hemorrhage.

BACKGROUND: Life-threatening abnormal uterine bleeding can be managed by a variety of techniques, which include intravenous estrogen, dilation and curettage, endometrial ablation, uterine artery embolization, or hysterectomy. Thermal balloon endometrial ablation has been used in the management of chronic dysfunctional uterine bleeding but has not been described in a case of acute uterine hemorrhage. CASE: A 44-year-old woman with end-stage liver disease presented with vaginal bleeding and fever. She was found to have sepsis, coagulopathy, and anemia. No anatomic uterine pathology was identified. Antibiotics, intravenous estrogen, and blood products were administered, but heavy bleeding persisted. Thermal balloon ablation resulted in abrupt cessation of uterine bleeding. CONCLUSION: Thermal balloon ablation appears to be an effective method for management of acute uterine hemorrhage.

Acute fatty liver of pregnancy and acetaminophen toxicity leading to liver failure and postpartum liver transplantation. A case report.

BACKGROUND: Acute fatty liver of pregnancy is a rare entity. A MEDLINE English-language search from 1966 to the present revealed no reports of acetaminophen toxicity and acute fatty liver in pregnancy. CASE: An 18-year-old, African American woman, gravida 1, presented at 33 weeks' gestation with signs and symptoms consistent with acute fatty liver of pregnancy and fetal death. Markedly elevated transaminases prompted a search for other etiologies, and acetaminophen toxicity was diagnosed. Liver biopsy revealed acute fatty liver of pregnancy and toxin-induced injury consistent with acetaminophen use. The patient's condition deteriorated, resulting in fulminant hepatic failure and requiring postpartum orthotopic liver transplantation. CONCLUSION: The combination of acute fatty liver of pregnancy and acetaminophen toxicity resulted in acute liver failure. Attention to clinical and biochemical parameters can lead to diagnosis and management.