The Manchester repair: an instructional video.

OBJECTIVE: The Manchester repair, developed in the UK by Donald, described in 1908, and later modified by Fothergill, is a well-studied and proven surgical treatment for uterovaginal prolapse when uterine preservation is desired. This operation is currently not widely performed in parts of the world (USA) but is becoming increasing popular in Europe. The objective of this video is to demonstrate our surgical technique and recommendations for successful completion of the procedure. METHODS: This patient is a 39-year-old woman with two previous vaginal deliveries who presented with a 1-year history of vaginal protrusion. She had no urinary or bowel symptoms. On examination, she had a grade 2 cystocele and uterine descent. She desired surgical management of her uterovaginal prolapse but wished to retain her uterus. The procedure involves mobilizing the vagina and bladder off the cervix and uterosacral cardinal ligament complex anteriorly and laterally. The cervix is then amputated. The ligaments are clamped, cut, and ligated and attached to the anterior cervical remnant with an overlapping suture. This pulls the cervix backward into the pelvis and results in anteversion of the uterus. A posterior and then anterior Sturmdorf suture is used to reconstruct the cervix by covering the amputated cervix with vaginal mucosa. CONCLUSION: The Manchester repair is an operation worth considering in patients where preservation of the uterus is desired. It uses native tissue and has a low complication rate and good long-term results.

Anterior bladder flap neo urethra as treatment for stress urinary incontinence due to developmental urogenital anomaly.

Congenital anomalies that involve the distal segment of urogenital sinus (giving rise to female urethra and vagina) may lead to abnormal urethral development ranging from absent to markedly deficient urethra. The abnormal division may also cause a short and patulous urethra. Sphincteric defects are likely to be associated and when combined with the short urethral length is a cause for severe urinary incontinence. Urinary incontinence due to a congenital cause requiring repeated urethral reconstruction to relieve symptoms is presented. A 15 year old girl was referred for bothersome urinary incontinence due to a short, wide, patulous urethra with defective sphincteric mechanism as part of urogenital sinus developmental anomaly. She was initially managed by reconstruction of bladder neck and proximal urethra with sphincter augmentation using autologous pubovaginal sling. Persistent urinary incontinence demanded a second urethral reconstruction using tubularised anterior bladder flap (modified Tanagho). Surgical reconstruction of the urethra achieved socially acceptable continence.

Vesicouterine fistulae: our experience of 17 cases and literature review.

AIM: A retrospective study of vesicouterine fistulae managed from 1996 to 2011 analyzed the incidence, symptomatology, diagnosis, and surgical outcome. PATIENTS & METHODS: During the study period, 17 patients were managed, of whom 14 underwent abdominal repair and three underwent vaginal repair. Mean patient age was 31.1 years and mean follow-up 7.3 years. RESULTS: Vesicouterine fistulae resulted following cesarean section in 13 patients and vaginal delivery in four. Eleven patients presented with urinary leakage via the vagina and seven with menouria. All patients had successful outcomes irrespective of treatment approach. The uterus was conserved in ten patients, of whom seven had completed their childbearing. The remaining three conceived spontaneously and underwent elective cesarean section. CONCLUSION: The majority of vesicouterine fistulae occur following cesarean section, and it is feasible to achieve 100 % successful repair. Though the majority require abdominal repair, a few selected cases can be successfully repaired vaginally.

Vaginal mesh repair: is it appropriate for pelvic organ prolapse in a nulliparous female following pelvic ring fracture?

Pelvic organ prolapse (POP) in a nulliparous woman is a rare sequela of high-energy pelvic trauma. We report a case of a 26-year-old nulliparous woman who developed stage III pelvic organ prolapse two decades after pelvic ring disruption. Abdominal wall cervicopexy was performed as a primary procedure by her attending local gynecologist. Recurrence occurred in early postoperative period following which she was referred to our institute. Examination revealed 5-cm pubic symphysis widening and stage III pelvic organ prolapse with deficient perineal body. Widened levator hiatus with atrophic pelvic floor muscles were confirmed on MRI. The patient was successfully managed by sacrospinous hysteropexy using predesigned vaginal mesh kit along with anterior colporrhaphy and colpoperineorrhaphy. Mesh exposure detected at the 6th year of follow-up required partial excision of the exposed mesh.

Management of ureterovaginal fistulae: an audit.

INTRODUCTION AND HYPOTHESIS: A retrospective study was done from January 2008 to January 2011 to analyze the outcome of ureterovaginal fistula management in relation to intervention mode. PATIENTS AND METHODS: Eighteen patients who developed ureterovaginal fistulae following gynecological and obstetric procedures were studied. Ureteroscopic stenting was attempted in 17 cases, and one patient electively underwent ureteral reimplantation. RESULTS: Ureteroscopic stenting was successfully accomplished in 13 of 17 patients; four patients underwent ureteral reimplantation, as stenting was not feasible. The success rate was 100 % at a mean follow-up of 24.6 months, irrespective of modality. CONCLUSION: The majority of iatrogenic ureterovaginal fistulae can be successfully managed by ureteroscopic stenting. Our study also suggests that ureteroscopic stenting should be considered as the primary mode of intervention in all cases. Ureteral reimplantation is required and remains practicable when stenting turns out to be impossible.

Trans-vaginal repair of gynecological supratrigonal vesicovaginal fistulae: A worthy option!

OBJECTIVE: To determine the appropriateness of vaginal approach for gynecological supratrigonal vesicovaginal fistulae. PATIENTS AND METHODS: Retrospective review of consecutive women with gynecological supratrigonal Vesico Vaginal Fistulae (VVF) repaired at the fistula unit of Urogynecology department between 1996 and 2011 was done.Out of 48 cases of supratrigonal VVF of gynecological origin identified; 34 (70.8%) cases were repaired vaginally and 14 (36.8%) abdominally with a mean follow-up period of 52.8 (2-132) months. RESULTS: Overall 95.8% were successfully cured at first attempt. The success rate of vaginal repair (94.8%) at first attempt was comparable to that of abdominal repair (100%) (P value = 0.8946). Amongst two failed vaginal repairs, one was successfully cured by subsequent vaginal repair and other by abdominal repair. CONCLUSION: Three fourth gynecological supratrigonal VVF can be repaired vaginally in first attempt with success rate comparable to abdominal approach. On the basis of this study we postulate that vaginal approach should be preferred over abdominal approach for repair of all vaginally accessible supratrigonal VVF of gynecological origin.

Irreducible procidentia due to multiple bladder calculi mimicking impacted faecal mass.

A case of massive irreducible procidentia with a hard palpable mass in the anterior vaginal wall mimicking an impacted faecal mass in a 57-year-old multiparous, post-menopausal woman is reported. Inability to walk, constipation and urinary incontinence were her primary complaints. Routine CT of the abdomen and pelvis excluded intestinal pathology, but failed to reveal multiple vesical calculi as the procidentia was lying outside the imaging zone of the pelvic CT. However, targeted plain X-ray and ultrasound of the prolapsed mass disclosed the existence of multiple vesical calculi. The patient was managed with single-stage laparotomy and vaginal hysterectomy. Hysterectomy permitted the reduction of the prolapse and facilitated extraperitoneal vesicolithotomy. Laparotomy excluded bowel pathology. No reconstructive surgical steps for repair and reconstruction were combined. Currently, the patient is relieved of all symptoms and her asymptomatic stage II vault prolapse is managed conservatively.

Vaginal repair of supratrigonal vesicovaginal fistulae--a 10-year review.

INTRODUCTION AND HYPOTHESIS: A 10-year retrospective study was done to determine the outcome of vaginal repair for supratrigonal vesicovaginal fistulae (VVF). METHODS: One hundred thirty-two urinary fistulae were managed from 2001 to 2011 which include 34 ureterovaginal and 98 lower urinary tract fistulae. Fifty-three out of 98 were supratrigonal VVF, 49 were of benign etiology and 4 were malignancy induced. Further analysis of 49 supratrigonal VVF of benign etiology revealed that 38 (77.5%) were of gynecological origin and 11 (22.5%) obstetric. Forty-three were primary and six were recurrent VVF. Thirty (61.2%) supratrigonal VVF were repaired vaginally and 19 (38.8 %) abdominally. Mean follow-up period was 51.7 months. RESULTS: The successful outcome for vaginal and abdominal repair was 86.7% and 100%, respectively (p value = 0.26). Overall, 91.8% supratrigonal VVF were cured at our first attempt. CONCLUSIONS: Majority of supratrigonal VVF can be approached vaginally with success rate comparable to abdominal approach.

Lumbosacral spondylodiscitis: an unusual complication of abdominal sacrocolpopexy.

Lumbosacral spondylodiscitis, an unusual complication of abdominal sacrocolpopexy using synthetic polypropylene mesh is reported. A young sexually active female with stage IV pelvic organ prolapse was managed with abdominal hysterectomy and sacrocolpopexy. Cervical dysplasia demanded hysterectomy and sacrocolpopexy was done to achieve good long-term results. Mesh exposure was noticed in the early post-operative period which initially responded to conservative management. Eight weeks later, the patient reported with severe pain in lower back restricting her physical movements and ambulation. Further evaluation with magnetic resonance imaging (MRI) confirmed lumbosacral spondylodiscitis, due to the infected mesh which warranted a complete removal of mesh by laparotomy. Removal of the mesh completely relieved her symptoms. Repeat MRI revealed resolving spondylodiscitis. The removal of mesh by itself was adequate to relieve her and discectomy was not required. The vault remained well supported despite removal of mesh.

Case of longitudinal vaginal septum with pelvic organ prolapse.

Longitudinal vaginal septum is a rare mullerian anomaly and its association with pelvic organ prolapse (POP) is unusual. A case of longitudinal vaginal septum with stage IV POP in a 35-year-old multiparous woman is being reported. Examination revealed an incomplete longitudinal vaginal septum (9 x 6 x 2 cm) with stage IV POP. Vaginal hysterectomy with repair and reconstruction was done along with excision of the longitudinal vaginal septum which was technically challenging due to proximity to rectum. This is the only case report of stage IV pelvic organ prolapse associated with a thick longitudinal vaginal septum in a multiparous woman without any obstetric complications. Surgery required increased caution per operatively while dissecting the septum from the vaginal wall and the adjacent organs.