Anterior Bilateral Sacrospinous Ligament Fixation: A Safe Route for Apical Repair.

OBJECTIVES: Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. METHODS: This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. RESULTS: In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. CONCLUSIONS: Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

Hysterectomy at the time of colpocleisis: a decision analysis.

INTRODUCTION AND HYPOTHESIS: Colpocleisis is an obliterative procedure for the treatment of pelvic organ prolapse (POP) with success rates nearing 100 %. Concomitant hysterectomy is commonly performed to avoid potential difficulty or delay in diagnosis and management of endometrial cancer (EMC). The objective was to assess the utility of vaginal hysterectomy at the time of a colpocleisis using decision analysis. METHODS: A decision analysis model was constructed to compare the outcomes of Le Fort colpocleisis (C) with those of colpocleisis and concomitant vaginal hysterectomy (CH). Probability and utility values from published data and expert opinions were utilized. As EMC risk changes with age, the total expected utility for each alternative was calculated for each decade using the rollback method. Sensitivity analysis was performed using Monte Carlo simulation. When evaluating specifically the risk of developing EMC in those patients with uterine conservation (C) and the risk of laparotomy in patients undergoing CH, one-way sensitivity analysis was used to determine a threshold for decision reversal. Two-way sensitivity analysis determined a threshold for complications common to both C and CH. RESULTS: The expected overall utility for C was higher than for CH for all ages 30-90 years. This difference was statistically significant for ages 40-90, favoring C. The Monte Carlo simulation results confirmed that the difference between the two alternatives was statistically significant. Multiple one-way sensitivity analyses confirmed model robustness. CONCLUSIONS: Colpocleisis should be preferred to CH. Concomitant hysterectomy commonly performed for cancer may be justified in patients younger than 40 years of age.

Use of Bakri balloon for treatment of persistent hematocolpos after a LeFort Colpocleisis: a case report.

LeFort colpocleisis is a simple and effective procedure for pelvic organ prolapse in women who no longer wish to preserve coital function. If the vaginal channels created during this procedure are not large enough, blood or pus may collect within the uterus or proximal vagina. Hematocolpos, accumulation of blood in apical vagina, may be difficult to manage especially when a patient is frail and has medical comorbidities. Here, we present a case of LeFort colpocleisis in which excessive anticoagulation led to an infected hematocolpos and persistent bleeding. This was successfully managed with a Bakri balloon via a vaginal channel without recurrence of her prolapse.

Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis.

INTRODUCTION AND HYPOTHESIS: A recent randomized controlled trial (RCT) with and without prophylactic antibiotics (pABX) for midurethral slings (MUS) was terminated early owing to lower than predicted infectious complications in both groups. Adequate power required an unattainable sample size. Because of low infectious risks, omitting pABX may be justified. Since an RCT was not feasible, we aimed to use decision analysis modeling to determine if pABX are necessary for MUS. METHODS: We created a decision analysis model comparing 1-year quality adjusted life years (QALYs) between women who do and do not receive pABX for MUS. The model included complications that might differ depending on whether antibiotics were given, such as allergic reaction to pABX (mild/severe), vulvovaginal candidiasis, urinary tract infections including pyelonephritis, pseudomembranous colitis, wound infection, and mesh erosion. Multiple one-way sensitivity analyses confirmed model robustness. RESULTS: One year after MUS, women who did not receive pABX had higher average QALYs than pABX (0.989 vs 0.977). This difference is less than published minimally important differences (MID) for utilities, suggesting that the strategies are comparable. Ultimately, pABX increased some complications and reduced others with an overall minimal effect on outcomes. Very few thresholds were identified, indicating model robustness and strengthening our conclusions. CONCLUSIONS: Women had slightly higher overall QALY when pABX were not given, but not greater than the MID. Since infectious complications are rare, our model suggests that pABX might be an unnecessary precaution because of similar outcomes with and without pABX.

Vaginal myofibroblastoma with prostatic glands: is there an association with tamoxifen use? A case report.

BACKGROUND: Both ectopic prostate tissue in the female genital tract and vaginal myofibroblastoma have rarely been reported in the literature. Tamoxifen use has been associated with the development of vaginal myofibroblastoma. CASE: A 76-year-old, multiparous woman who had taken tamoxifen for breast cancer presented with postmenopausal bleeding and a vaginal mass. Endometrial work-up revealed a benign polyp, and the polypoid tumor in the vagina was found to be a myofibroblastoma harboring ectopic prostatic glands. CONCLUSION: To our knowledge this is the first case of these two rare pathologic entities occurring together. Of note, this patient also had a history of tamoxifen therapy, like some of the previous patients with vaginal myofibroblastoma.

Massive subcutaneous emphysema in robotic sacrocolpopexy.

The advent of robotic surgery has increased the popularity of laparoscopic sacrocolpopexy. Carbon dioxide insufflation, an essential component of laparoscopy, may rarely cause massive subcutaneous emphysema, which may be coincident with life-threatening situations such as hypercarbia, pneumothorax, and pneumomediastinum. Although the literature contains several reports of massive subcutaneous emphysema after a variety of laparoscopic procedures, we were not able to identify any report of this complication associated with laparoscopic or robotic sacrocolpopexy. Massive subcutaneous emphysema occurred in 3 women after robotic sacrocolpopexy in our practice. The patients had remarkable but reversible physical deformities lasting up to 1 week. A valveless endoscopic dynamic pressure system was used in all 3 of our cases. Our objective is to define the risk of massive subcutaneous emphysema during robotic sacrocolpopexy in light of these cases and discuss probable predisposing factors including the use of valveless endoscopic dynamic pressure trocars.

Minimally invasive diagnosis and treatment of endometrial cancer after LeFort colpocleisis.

BACKGROUND: Endometrial carcinoma is rare after LeFort colpocleisis. Standards for its diagnosis and treatment have not been established. CASE: A 74-year-old woman presented with postmenopausal bleeding 14 months after LeFort colpocleisis. Here, we describe the use of the colpocleisis channels in our novel 2-stage approach. In the first stage, endometrial carcinoma was diagnosed with vaginohysteroscopy and dilatation and curettage via the channels. In the second stage, the cancer was optimally treated with total robotic hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection. Assistance and specimen retrieval were achieved through the vaginal channels. The patient recovered without compromise to the pelvic floor. CONCLUSIONS: Endometrial cancer after LeFort colpocleisis can be diagnosed and treated with minimally invasive approaches without disrupting the colpocleisis or the pelvic floor support.

Is antibiotic prophylaxis necessary for midurethral sling procedures? A series of 174 cases without preoperative antibiotics.

INTRODUCTION AND HYPOTHESIS: Despite the lack of evidence, antibiotic prophylaxis has been recommended for midurethral sling procedures. The goal of this study was to evaluate the rate of infectious complications in women undergoing midurethral sling procedures without antibiotic prophylaxis. METHODS: We reviewed the baseline characteristics and postoperative infectious complications of 174 consecutive women who underwent midurethral sling procedures without prophylactic antibiotics from April 2005 to January 2010. Patients undergoing concomitant vaginal surgery were excluded. RESULTS: The average age, parity, and body mass index of were 51.3 ± 12.6 years, 2.4 ± 1.3, and 30.1 ± 7.4 kg/m(2), respectively. There were no wound infections, 2 (1.4%) vaginal mesh exposures and 12 (8%) cases of bacteriuria. CONCLUSIONS: The risk of infections is low when a midurethral sling is performed without antibiotic prophylaxis. Antibiotic prophylaxis does not appear to offer any benefit in midurethral sling procedures.

Double-blinded randomized trial of preoperative antibiotics in midurethral sling procedures and review of the literature.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to determine if prophylactic antibiotic use before midurethral sling procedures reduces infectious complications. METHODS: In this double-blinded randomized trial, we compared infectious complications between women who received cefazolin and placebo before midurethral sling procedures. RESULTS: The study was halted due to low rate of infectious outcomes seen at the first scheduled interim analysis. We enrolled 29 women in the cefazolin group and 30 in the placebo group. Total follow-up was 6 months (3-24 months). The groups were similar at the baseline. There was no statistically significant difference between the cefazolin and placebo groups, respectively, with respect to wound infections [1 (3.3%) and 0 (0%)], mesh exposure [0 (0%) and 1 (3.5%)], and bacteriuria [3 (10%) and 1 (3.5%)]. CONCLUSION: Because infection rates are low in both cefazolin and placebo groups, omitting preoperative antibiotics for midurethral slings may be justified.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures.

OBJECTIVES: To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a woman's lifespan. METHODS: Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed. RESULTS: More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a woman's lifetime. CONCLUSION: Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women. LEVEL OF EVIDENCE: III.

Using lubricant for speculum insertion.

Speculum insertion can be associated with considerable discomfort during routine pelvic examination. Physiologically, vaginal entry requires lubrication. However, traditional teaching recommends, if anything, warm water only for lubrication, because lubricants are believed to interfere with Pap and infection tests. There is level I evidence that modest lubrication of the external surface of the speculum does not impair cytologic and infectious evaluation of the cervix. This should be reflected in contemporary teaching and guidelines.

Vaginal evisceration during pessary fitting and treatment with immediate colpocleisis.

BACKGROUND: Complications from pessaries are rare and occur predominantly as a result of neglect and loss to follow-up. We report a case of vaginal evisceration at the time of pessary insertion, which was repaired with concomitant colpocleisis. CASE: An 82-year-old woman with stage IV pelvic organ prolapse (POP) presented for a routine pessary fitting, which resulted in vaginal evisceration and displacement of the pessary into the abdomen. She was treated successfully with immediate colpocleisis after transvaginal removal of the pessary and repair of the rupture site. CONCLUSION: Pessary insertion can result in vaginal evisceration. Both POP and vaginal rupture can be successfully treated with removal of the pessary, closure of the vaginal defect, and LeFort colpocleisis all in one session.

Pessary use in pelvic organ prolapse and urinary incontinence.

With the aging population in the United States, there has been a renewed interest in pessaries as a conservative alternative to surgical repair for pelvic organ prolapse (POP). They present a good option for patients who have not completed childbearing, do not desire surgery, or are poor surgical candidates. Long-term pessary use is a safe and effective option for patients with POP and stress urinary incontinence. Although serious side effects are infrequent, insertion and removal of most pessary types still pose a challenge for many patients. Pessary design should continue to improve, making its use a more attractive option.

Trends in inpatient prolapse procedures in the United States, 1979-2006.

OBJECTIVE: We sought to describe national trends for inpatient procedures for pelvic organ prolapse from 1979-2006. STUDY DESIGN: The National Hospital Discharge Survey was analyzed for patient and hospital demographics, as were International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedures codes from 1979-2006. Age-adjusted rates (AARs) per 1000 women were calculated using the 1990 US Census data. RESULTS: There was a significantly decreasing trend in the AARs for inpatient prolapse procedures, from 2.93-1.52 per 1000 women from 1979-2006. AARs for hysterectomy decreased from 8.39-4.55 per 1000 women from 1979-2006. Over the study period, AARs remained at about the 1979 level among the women>or=52 years old (2.73-2.86; P=.075). In women<52 years old, AARs declined to less than one-third of the 1979 rate (3.03-0.84; P<.001). CONCLUSION: AARs for inpatient procedures for prolapse in the United States remained stable for women aged>or=52 years from 1979-2006; rates declined by two-thirds for women aged<52 years.

Retropubic and transobturator midurethral slings: a decision analysis to compare outcomes including efficacy and complications.

INTRODUCTION AND HYPOTHESIS: The objective of this paper is to compare retropubic (RP) and transobturator (TO) midurethral slings using decision analysis techniques. METHODS: A decision analysis was constructed including efficacy and complication data. Probability of complication-free surgery and overall utility were analyzed using two models: ALL (all 42 trials) and RCT (seven randomized controlled trials with higher quality data, but missing data on some complications). RESULTS: Surgery was complication-free more frequently with TO approach with 83.7% vs. 55.7% (ALL) and 70.9% vs. 62.8% (RCT). One-year overall utility favored TO in the ALL model (0.943 vs. 0.895). Conversely, the RCT model favored RP (0.936 vs. 0.910). These differences were both less than published minimally important differences (MID) for utilities. Multiple one-way sensitivity analyses confirmed robustness of results. CONCLUSIONS: The difference between the two surgeries in both utility-based models was less than the MID. Therefore, the separate approaches are highly comparable with similar overall utility. Complications are more frequent with the retropubic approach.

Tensile properties of commonly used prolapse meshes.

INTRODUCTION AND HYPOTHESIS: To improve our understanding of the differences in commonly used synthetic prolapse meshes, we compared four newer generation meshes to Gynecare PS using a tensile testing protocol. We hypothesize that the newer meshes have inferior biomechanical properties. METHODS: Meshes were loaded to failure (n = 5 per group) generating load-elongation curves from which the stiffness, the load at failure, and the relative elongation were determined. Additional mesh samples (n = 3) underwent a cyclic loading protocol to measure permanent elongation in response to subfailure loading. RESULTS: With the exception of Popmesh, which displayed uniform stiffness, other meshes were characterized by a bilinear behavior. Newer meshes were 70-90% less stiff than Gynecare (p < 0.05) and more readily deformed in response to uniaxial and cyclical loading (p < 0.001). CONCLUSION: Relative to Gynecare, the newer generation of prolapse meshes were significantly less stiff, with irreversible deformation at significantly lower loads.