Incidence and risk factors for chronic pelvic pain after hysteroscopic sterilization.

STUDY OBJECTIVE: To investigate the incidence of and preoperative risk factors for developing pelvic pain after hysteroscopic sterilization using the Essure microinserts. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University medical center. PATIENTS: A total of 458 patients who underwent hysteroscopic sterilization using Essure between January 1, 2005, and June 30, 2012. INTERVENTION: Hysteroscopic sterilization using Essure. MEASUREMENTS AND MAIN RESULTS: The incidence of acute pelvic pain after hysteroscopic sterilization was 8.1%, and of persistent pain at 3 months after the procedure was 4.2%. The range of presence of pain was 1 to 469 days (mean, 56 days). Of patients who developed chronic pelvic pain after the procedure, 75% reported it within 130 days of the procedure. Patients with previous diagnoses of any chronic pain (chronic pelvic pain, chronic low back pain, chronic headache, and fibromyalgia) were more likely to report both acute pain (odds ratio, 6.81; 95% confidence interval, 2.95-15.73) and chronic pain (odds ratio, 6.15; 95% confidence interval, 2.10-18.10) after hysteroscopic sterilization. CONCLUSIONS: Pelvic pain may develop after hysteroscopic sterilization. Patients with a diagnosis of preexisting chronic pain may be at increased risk of developing pelvic pain after the procedure. Fifty percent of new pelvic pain after Essure placement will resolve within 3 months.

Ureteral transection due to intraperitoneal course of ureter after pediatric ureteral reimplantation.

BACKGROUND: Traditional pediatric ureteral reimplantation involved blindly passing a clamp behind the bladder to guide the ureter into a new hiatal opening, potentially resulting in an intraperitoneal ureter. CASE: A 44-year-old woman with previous ureteral reimplantation underwent gynecologic laparoscopy. Two fibrous bands attached a segment of small bowel to the abdominal wall. One band was transected and ligated. Postoperative suspicion that the bands represented ureter prompted computed tomography imaging, showing high-grade ureteral obstruction. Retrograde pyelogram revealed urinary extravasation and no continuity with the ureter. Reoperation with ureteroneocystotomy confirmed the bands were ureter coursing through bowel, consistent with injury during ureteral reimplantation. CONCLUSION: Review of previous surgeries, a high index of suspicion, and prompt urologic consultation are recommended to identify and repair ureter injuries in abnormal anatomy cases.

An unusual presentation of uterine didelphys and obstructed hemivagina.

BACKGROUND: Congenital disorders of the genitourinary system can be unpredictable. There are both medical and surgical interventions that can help manage symptoms. CASE: A 10-year-old girl was evaluated 6 months post-menarche with dysuria and pelvic pain. Her symptoms were not relieved with menstrual suppression. Evaluation revealed a probable ectopic ureter versus ureterocele and uterine didelphys with suspicion for obstructed hemivagina and hematocolpos. Surgical exploration revealed an obstructed hemivagina with a high vaginal septum. When resection failed, she ultimately underwent a robot-assisted hemihysterectomy, with resolution of her symptoms. SUMMARY AND CONCLUSIONS: In this case presentation, a surgical approach was necessary to adequately make a diagnosis. When vaginal septum resection failed, robot-assisted laparoscopic hemi-hysterectomy and resection of a vaginal pouch led to symptom resolution in this pediatric patient with a complex anomaly.

Venous thromboembolism and use of prophylaxis among women undergoing laparoscopic hysterectomy.

OBJECTIVE: To examine the risk of venous thromboembolism and the use of venous thromboembolism prophylaxis in women undergoing laparoscopic hysterectomy. METHODS: Results of women recorded in a health outcomes, resource utilization, and quality database from 2003 to 2007 who underwent laparoscopic hysterectomy were analyzed. The rate and predictors of venous thromboembolism as well as patterns of venous thromboembolism prophylaxis were examined. Multivariable logistic regression models were developed to determine the incidence of venous thromboembolism and use of any prophylaxis, as well as pharmacologic prophylaxis. RESULTS: Among 60,013 women, a total of 579 (1.0%) venous thromboembolism events were noted. Venous thromboembolism was diagnosed in 2.1% of women aged 60 years or older and in 2.3% of those with cancer. Women older than 60 years (OR 1.64, 95% CI 1.19-2.26) and with more medical comorbidities (OR 3.07, 95% CI 2.23-4.23) were most likely to have a venous thromboembolism develop. A total of 23,562 (39.3%) patients received no venous thromboembolism prophylaxis, 29,288 (48.8%) received mechanical prophylaxis, and 7,163 (11.9%) received pharmacologic prophylaxis. Women aged 60 years or older (OR 1.56, 95% CI 1.41-1.73), women with more medical comorbidities (OR 1.93, 95% CI 1.71-2.17), those with cancer (OR 3.08, 95% CI 2.75-3.45), and patients treated by high-volume surgeons (OR 1.42, 95% CI 1.33-1.52) were more likely to receive pharmacologic prophylaxis. CONCLUSION: Whereas patients undergoing laparoscopic hysterectomy are overall at low risk for venous thromboembolism, older women, those with medical comorbidities, and women with cancer are at substantial risk. Venous thromboembolism prophylaxis is highly variable and often not utilized.