Extraperitoneal laparoscopic colposuspension: short-term cure rate, complications, and duration of hospital stay in comparison with Burch colposuspension.

OBJECTIVE: To compare duration of surgery, length of hospital stay, complications, and short-term cure rate of extraperitoneal laparoscopic colposuspension with that of Burch colposuspension. METHODS: We retrospectively reviewed 157 consecutive cases of extraperitoneal laparoscopic (n=70) or Burch colposuspension (n=87) performed between January 1, 1995, and June 30, 1997. Cure rate was assessed by history, physical examination, and questionnaire. Patients not requiring the use of pads were considered continent. Cure rates were compared in the entire group, whereas complications, duration of surgery, and length of stay were compared only in subgroups undergoing colposuspension alone. Results were analyzed statistically. RESULTS: The mean times to follow-up were 12.9 months (laparoscopic group) and 16.3 months (Burch group). At last follow-up, 64 of 70 (91.4%) of the laparoscopic and 80 of 87 (92%) of the Burch colposuspension group were continent. In patients who underwent colposuspension alone, results were as follows for those who underwent laparoscopic (19) and Burch (21) procedures, respectively: average duration of surgery, 49.2 compared with 62.6 minutes (P < .03); average hospital stay, 14 hours compared with 2.7 days (P < .001); average postoperative disability period, 1.6 weeks compared with 4.7 weeks (P < .001); incidence of complications, 15.8% compared with 33.3% (P=.170). CONCLUSION: Extraperitoneal laparoscopic colposuspension, compared with Burch colposuspension, resulted in similar short-term cure rates and complications, shorter duration of surgery, hospital stay, and convalescence. It is a feasible option in treatment of stress urinary incontinence when laparotomy is not required.

Extraperitoneal laparoscopic colposuspension for genuine urinary stress incontinence.

STUDY OBJECTIVE: To evaluate endoscopic colposuspension with extraperitoneal and direct entry into the space of Retzius. DESIGN: Prospective case series (Canadian Task Force classification II-1). SETTING: University of Texas Health Science Center and unaffiliated private practice, San Antonio, Texas. PATIENTS: Seventy women with genuine urinary stress incontinence. INTERVENTION: The space of Retzius was entered directly through a 1.5-cm incision about 2 inches above the symphysis pubis. Three cannulas were inserted at the suprapubic area to access extraperitoneum. Permanent sutures were introduced into the space of Retzius, and with a 5-mm needle holder a double bite was taken into paravaginal fascia on either side. Cooper's ligaments were identified and the needle was passed through the ligaments medial to obturator vessels. To secure sutures, we used a simple surgical knot followed by square knots with either extracorporeal or intracorporeal method. Paravaginal fascia was pulled toward Cooper's ligaments to produce a zero-degree Q-Tip angle in the urethra. MEASUREMENTS AND MAIN RESULTS: Of 70 women, 64 (91.4%) were clinically continent after surgery. Average duration of follow-up so far is 15.9 months. Twenty-nine patients were managed as short-stay admissions, and average length of hospital stay for women who had only colposuspension was 14 hours. Two cases were converted to laparotomy, and two patients had endoscopic repair of bladder perforation. CONCLUSION: Extraperitoneal laparoscopic Burch colposuspension produced direct access to the space of Retzius with satisfactory visualization and acceptable outcome. It may be performed as a short-stay procedure in selected patients.

Comparison of sonography, sonohysterography, and hysteroscopy for evaluation of abnormal uterine bleeding.

We compared transvaginal sonography, sonohysterography, and diagnostic hysteroscopy in the evaluation of abnormal uterine bleeding, Sixty-eight women 40 or older with abnormal uterine bleeding were assigned to undergo either transvaginal sonography or sonohysterography. All subjects then had diagnostic hysteroscopy and endometrial biopsy. Patients with abnormal findings underwent operative hysteroscopy or definitive therapy. Transvaginal sonography, sonohysterography, and diagnostic hysteroscopy revealed a sensitivity of 95%, 90%, and 78%, and a specificity of 65%, 83%, and 54%, respectively. The average cost for transvaginal sonography of sonohysterography was $195 and the cost for diagnostic hysteroscopy was $675. Transvaginal sonography and sonohysterography are cost-effective alternatives and more sensitive diagnostic tests than office diagnostic hysteroscopy.

Complications of major operative laparoscopy. A review of 452 cases.

OBJECTIVE: To evaluate complications of operative laparoscopy. STUDY DESIGN: Operative and postoperative complications in 452 consecutive cases from January 1, 1991, to August 31, 1993, were evaluated. The series was divided into three time segments--8, 12 and 12 months. Common and serious complications were classified and reviewed. RESULTS: Complications developed during and after major operative laparoscopy in 47 (10.4%) patients in the series; 24 (5.3% of cases, or 51% of total complications) were serious, such as hemorrhage, ureteral injuries and fistulas, and intestinal obstruction. Seventeen (3.8%) patients required unplanned surgery for management of complications. During the initial learning period of eight months, the rate of complications averaged 17.3%, decreasing to 7.7% and 10.1%, respectively, in the second and third periods in the series. There were no cases of death, postoperative ileus, thrombophlebitis or pulmonary complications. CONCLUSION: The overall incidence of complications in major operative laparoscopy was 10.4%. Serious complications accounted for half the complications. Surgical experience reduced the incidence of complications. Ovarian cystectomy produced the lowest rate of common complications and no serious ones. Laparoscopically assisted vaginal hysterectomy had the highest rate of serious complications.

Diagnosis and management of serious urinary complications after major operative laparoscopy.

OBJECTIVE: To evaluate the incidence, diagnosis, and management of serious urinary complications after major operative laparoscopy. METHODS: For this retrospective study of 953 consecutive cases of major operative laparoscopy from January 1, 1990, to December 31, 1994, we reviewed incidence, method of diagnosis, and management of complications. Urinary complications included bladder injuries, urinary fistulas, and ureteral injuries. Major operative laparoscopic procedures included hysterectomy, adnexectomy, treatment of tubal pregnancy, ovarian cystectomy, and ablation-fulguration of severe endometriosis (stage IV). RESULTS: Serious urinary complications were found during or after operative laparoscopy in 15 of 953 patients (1.6%, 95% confidence interval [CI] 0.8-2.4). Four ureteral injuries, three bladder fistulas, and eight bladder perforations were documented in this series. Eight cases of urinary complications were recognized during the original surgery (one ureteral injury and seven bladder injuries) and repaired at that time. Laparotomy or additional major surgery was performed in seven patients (three ureteral injuries, two bladder fistulas, and two bladder perforations). CONCLUSIONS: Serious urinary complications after major operative laparoscopy were discovered in 1.6% of patients. This incidence compares favorably to serious urinary complications after standard gynecologic surgery. Intraoperative recognition of these complications will likely avoid additional surgery.

Intestinal obstruction and bilateral ureteral injuries after laparoscopic oophorectomy in a patient with severe endometriosis.

The overall frequency of ureteral injury during laparoscopic adnexectomy for endometriosis is unknown, and intestinal obstruction after laparoscopy is rare. Our patient had two postoperative complications: small bowel obstruction and bilateral ureteral injuries discovered 2 and 39 days, respectively, after outpatient laparoscopic adhesiolysis and bilateral salpingo-oophorectomy for severe endometriosis. Pelvic examination and vaginal sonography revealed a large unilocular cystic mass. Laparoscopy showed a fixed large endometrioma firmly attached to pelvic peritoneum and intestines in the pelvic cavity, and significant adhesions in the upper part of a midline incision from prior abdominal hysterectomy. These midabdominal adhesions were not released. The patient underwent laparoscopic bilateral adnexectomy as an outpatient. Two days later she was admitted with small bowel obstruction. Thirty-nine days later, diagnostic evaluation revealed urinary ascites with right ureteral stricture at the uterine artery level, and complete ligation and resection of the left ureter at the pelvic brim near the infundibulopelvic ligament stump. She underwent left ureteral implantation with psoas hitch and right ureterolysis. Follow-up cystogram and intravenous pyelography at 6 and 20 weeks revealed complete recovery. In cases of severe endometriosis with significant ureteral and intestinal involvement, laparotomy may have to be considered.

Comparison of office loop electrosurgical conization and cold knife conization.

A group of 98 patients with abnormal Papanicolaou smears underwent cold knife conization or loop electrosurgical conization after colposcopic examination and biopsy. Average duration of surgery, intraoperative bleeding, rate of complications, and cost of the procedure were significantly less for the electrosurgical conization group. We conclude that this procedure may be performed in the office in place of hospital cold knife conization for the diagnosis and treatment of cervical intraepithelial neoplasia.

Diagnostic and therapeutic conization using loop radiothermal cautery.

A group of 173 patients with abnormal cervical cytology underwent diagnostic or therapeutic conization following colposcopic examination. The series includes 23 patients with cold knife conization in the hospital under general anesthesia, 12 patients with an outpatient KTP laser procedure under local anesthesia, 53 patients with an outpatient CO2 laser procedure under local anesthesia, 10 patients with hospital-based loop radiothermal cautery conization and 75 patients with loop radiothermal cautery conization in the office under local anesthesia. Loop radiothermal cautery conization was advantageous, with a shorter duration of surgery, lower cost, reduced operative bleeding, less of a need for pain-relieving medication and shorter duration of postoperative disability. Cold knife conization patients had the most intraoperative bleeding and the longest hospitalization. KTP laser conization produced specimens of inferior quality, resulting in the least satisfactory histologic diagnosis. Office-based loop radiothermal cautery conization may be preferable to other methods of conization in the diagnosis and management of squamous intraepithelial lesions.

First-trimester bleeding and the vanishing twin. A report of three cases.

Ultrasonic examination of early pregnancies can lead to the discovery of vanishing twins. The main reason for such an evaluation is bleeding in the first trimester. Three women came to the emergency room of a community hospital with pelvic cramps and significant uterine bleeding containing clots. In two cases the cervix was soft and dilated, but in no case was the uterus smaller than was appropriate for the gestational age. Ultrasonic evaluation revealed a set of twins in all three patients. Patient 1 experienced early disappearance of a gestational sac (before ten weeks). Ultrasound demonstrated a blighted ovum in patient 2 until the 24th week of pregnancy. Macroscopic examination of patient 2's placenta at the birth of a normal, term, singleton infant revealed a compressed gestational sac. Patient 3 had developed a fetus papyraceous of 26 weeks' gestational size along with a normal singleton pregnancy. The only apparent complication associated with disappearance of a twin was first-trimester bleeding. Apparently a vanishing twin need not adversely affect the development of a coexisting singleton pregnancy. Therapeutic dilation and curettage for threatened or inevitable abortion should be avoided until a sonogram rules out the presence of a potentially surviving twin.

Direct laparoscopy without prior pneumoperitoneum.

It has been assumed that pneumoperitoneum is a requirement prior to insertion of the laparoscope trocar and sleeve. The results of direct trocar insertion without prior establishment of pneumoperitoneum were documented in 1,108 consecutive laparoscopies. No technical failures or operative complications attributable to the method were encountered. In sterilization procedures using the Falope Ring, less than 1L of carbon dioxide was used, resulting in less post-operative abdominal and shoulder pain. Subcutaneous hemorrhage was significant, although all the symptoms disappeared without treatment. Use of this method with obese patients created no major problem.

The hazard of cryosurgery for treatment of cervical dysplasia.

Cryosurgery was used to treat patients with cervical dysplasia and cervicitis during a 44-month period. The course of dysplasia following cryosurgery in these patients has been evaluated and compared to the course of dysplasia in similar patients who were untreated or treated with biopsy only. When the groups with moderate and severe dysplasia are combined, a significantly greater number of patients treated with cryosurgery had progression of dysplasia in comparison to those patients in the untreated group. The disadvantages of cryosurgery are discussed, and criteria for evaluation of dysplasia prior to cryosurgery are outlined.

Management of cervical neoplasia with colposcopy.

During a 44-month period the introduction of colposcopy to a metropolitan dysplasia clinic resulted in 1, 144 colposcopic examinations on 442 patients. Agreement between colposcopically directed biopsy and final diagnosis was found in 84%, and directed biopsy revealed the most advanced lesion in 42.5%. Satisfactory colposcopy was performed on 93% of patients, and some degree of histologic abnormality was obtained in 86% of patients with colposcopic abnormalities. Undetected invasive cervical cancer occurred in both cervical conization and colposcopic examinations with equal frequency. Endocervical curettage detected two cases of occult invasive cancer, and increased use of this procedure is recommended. Guidelines for management of cervical neoplasia are suggested.