More With Less: Single-Incision Sling Insertion Techniques.

STUDY OBJECTIVE: To demonstrate reproducible procedures for efficient single-incision sling insertion and troubleshooting. DESIGN: Narrated video footage with stepwise demonstration of single-incision sling insertion technique with anchor system. SETTING: The mesh midurethral sling is a highly effective and safe procedure that is considered the gold standard for surgical treatment of stress urinary incontinence. Retropubic and transobturator approaches for midurethral slings have similar subjective cure rates with differing surgical risk profiles [1,2]. The retropubic route has a higher risk of injury to the bladder, nerves, and vascular structures, whereas the obturator approach carries a risk of groin or thigh pain [3-5]. Use of a single-incision sling decreases these risks and allows flexibility to perform the procedure without sedation or general anesthesia. Recent literature demonstrates similar subjective and objective success and safety of single-incision slings compared with both retropubic and transobturator approaches, although long-term data are forthcoming [5]. INTERVENTIONS: We demonstrate a stepwise approach for the insertion of a single-incision sling using a helical trocar. Easily reproducible procedures for setup and sling anchor management allow for efficient placement without assistance. In addition, we outline hand positioning, trocar management, and anchor deployment with troubleshooting techniques for potential placement difficulties. Finally, we review methods for sling tensioning to prevent complications such as voiding dysfunction and mesh or suture exposures. CONCLUSION: Given that single-incision slings are more likely to be performed under local anesthesia and are less invasive with decreased recovery time, it has the potential to become the preferred approach in the future. This video demonstrates clear and detailed steps to facilitate successful placement of the single-incision mesh midurethral sling.

Risk factors of lower urinary tract injury with laparoscopic sacrocolpopexy.

BACKGROUND: Lower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy. OBJECTIVE: The primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy. STUDY DESIGN: This was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios. RESULTS: A total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m2 (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48-160.38; P=.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05-23.19; P=.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21-8227; P=.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury. CONCLUSION: Although lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.

Sacrocolpopexy Techniques for the Savvy Surgeon.

Laparoscopic sacrocolpopexy (LSCP) can be challenging even for the experienced surgeon. Knowledge and adequate visualization of the sacral and pelvic anatomy is paramount to prevent potentially catastrophic intra-operative hemorrhage, nerve or ureteral injury, and to facilitate presacral dissection. We highlight several techniques to maximize surgical efficiency, optimize visualization of the sacral anatomy during presacral dissection, as well as a method to facilitate peritoneal closure over the mesh during LSCP. These techniques are generalizable, maximize surgical efficiency and safety, and can decrease frustration during LSCP.

Suprapubic Versus Transurethral Catheterization: Perioperative Outcomes After Colpocleisis.

OBJECTIVES: Transient postoperative urinary retention occurs in approximately half of women after colpocleisis; however, the optimal strategy for postoperative catheter management is unclear. This study compared length of catheterization and postoperative complications after colpocleisis between planned suprapubic catheter placement and transurethral catheterization. METHODS: This is a retrospective cohort study including all women undergoing colpocleisis from January 2015 to December 2019 in a large female pelvic medicine and reconstructive surgery practice. Women undergoing planned placement of a suprapubic catheter intraoperatively during colpocleisis and women who were discharged with a transurethral catheter after failing an active voiding trial postoperatively after colpocleisis were included. Women with surgical complications requiring prolonged catheterization and those needing catheterization before surgery were excluded. Length of catheterization and postoperative complications were compared between groups. RESULTS: Two hundred fifty-eight women underwent colpocleisis during the study time frame and 170 were eligible for analysis: with 78 in the planned suprapubic catheter group and 92 in the transurethral catheter group. Length of catheterization with suprapubic catheter placement was significantly longer than transurethral catheter placement with median catheter days of 11 (95% confidence interval [CI], 10-14) versus 7 (95% CI, 6-7), which persisted after adjustment (HR, 2.61, 95% CI, 1.85-3.68, P < 0.001). No significant differences were found in overall complications or urinary tract infections. CONCLUSIONS: Suprapubic catheter placement at the time of colpocleisis is associated with increased length of catheterization postoperatively compared with transurethral catheter for management of postoperative urinary retention. These data can aid surgeons in preoperative counseling and shared decision making with patients.

Effects of Preoperative Gabapentin on Clinical Outcomes After Outpatient Midurethral Sling Placement.

OBJECTIVES: This study aimed to evaluate transient urinary retention in women undergoing outpatient midurethral sling placement who received preoperative gabapentin (treated) versus those who did not (untreated). Secondary outcomes included unexpected admission rates, analgesic usage, time to discharge, and pain. METHODS: This was a retrospective cohort study including women who underwent outpatient midurethral sling placement from 2015 to 2019. Exclusion criteria included suprapubic catheter placement, planned overnight admission, abnormal preoperative postvoid residual volume, and prolonged postoperative catheterization. Logistic regression was performed to evaluate gabapentin usage and urinary retention after adjusting for patient characteristics. RESULTS: Three hundred two women met the inclusion criteria, with 19.5% experiencing urinary retention after midurethral sling placement. Women older than 65 years were more likely to have urinary retention than those aged 18-65 years (29.8% vs 17.6%, P = 0.054). Of treated participants, 26% had urinary retention versus 18% of untreated participants (P = 0.162). Adjusting for age, parity, pain, operative time, blood loss, sling type, analgesic, scopolamine patch, or hemostatic agent use, treated participants had 72% higher odds of urinary retention (adjusted odds ratio, 1.72; 95% confidence interval, 0.88-3.38; P = 0.113). There was no difference in unexpected admission, analgesic usage, time to discharge, or pain between groups. CONCLUSIONS: One of 5 women had urinary retention after outpatient midurethral sling placement. Although no statistically significant difference was found in urinary retention between groups, the odds of urinary retention in the treated group were increased. Because there was no difference in pain, analgesic usage, or time to discharge between groups, investigation regarding gabapentin use for outpatient urogynecologic surgery is needed.

Risk Factors for Urinary Retention After Colpocleisis.

OBJECTIVES: Transient urinary retention occurs frequently after pelvic organ prolapse surgery. While the prevalence of postoperative urinary retention has been reported for reconstructive procedures, a paucity of data exists for colpocleisis. The objectives of this retrospective cohort study were to identify risk factors for transient urinary retention after colpocleisis and to determine the rate of its occurrence. METHODS: A retrospective chart review was performed for patients undergoing colpocleisis from January 2015 to December 2019 in a high-volume urogynecology practice. Patients were excluded if they required prolonged catheterization postoperatively because of a surgical complication or used a catheter before surgery, or if a suprapubic catheter was placed during surgery. Potential patient and procedural risk factors were analyzed. Transient urinary retention was diagnosed if patients failed their postoperative voiding trial and went home with a catheter. RESULTS: A total of 172 patients met the inclusion criteria. The incidence of transient postoperative urinary retention was 55%, with rates of 36.7% with LeFort colpocleisis, 51.5% with posthysterectomy colpocleisis, and 64.9% with colpocleisis with concomitant hysterectomy. Logistic regression revealed an increased risk of postoperative urinary retention if hysterectomy was performed at the time of colpocleisis (odds ratio, 2.9; confidence interval, 1.23-6.84; P = 0.015). Patient age, prolapse severity, preoperative postvoid residual volume, and concomitant anti-incontinence procedure were not associated with transient postoperative urinary retention. CONCLUSIONS: Transient urinary retention occurs in more than half of patients after colpocleisis. Patients undergoing concomitant hysterectomy have the highest risk of postoperative urinary retention. Surgeons can use this information both for counseling and management decisions for individual patients.

Outside-In: Intraperitoneal Anterior and Posterior Plication During Prolapse Surgery.

OBJECTIVE: To demonstrate a novel technique of intraperitoneal vaginal wall plication combining the benefits of anterior and posterior colporrhaphy with laparoscopic sacrocolpopexy. DESIGN: Video demonstration of laparoscopic anterior and posterior colporrhaphy techniques, highlighting the various clinical scenarios in which they would be beneficial. SETTING: Sacrocolpopexy is recommended for the treatment of advanced-stage prolapse [1-3]. Frequently, these patients have significant vaginal elongation and laxity that can make reconstruction challenging. This case series performed at a tertiary care hospital highlights a series of women undergoing laparoscopic sacrocolpopexy whose repairs were optimized with the use of intraperitoneal vaginal wall plication. INTERVENTIONS: A series of plication stitches using delayed absorbable suture is placed on redundant anterior or posterior vaginal walls. This technique reduces excess vaginal tissue and reinforces the reconstruction. Stitches can be placed vertically or horizontally to narrow the vagina, depending on the repair needs. Vertical plication shortens the vaginal walls and provides additional traction to allow dissection extension to the trigone anteriorly or the rectovaginal septum posteriorly, thus optimizing mesh placement [4]. This plication also adds bulk to the vaginal tissue where the mesh is attached, potentially decreasing the risk of mesh exposure. CONCLUSION: Intraperitoneal vaginal wall plication is the outside-in version of anterior and posterior colporrhaphy. This novel technique can optimize dissection and mesh placement and provide support for attenuated vaginal walls. It also balances the ratio of mesh to vaginal tissue without increasing mesh burden.

Urinary symptoms in women receiving carboplatin/paclitaxel for treatment of gynecologic cancers.

OBJECTIVES: Urinary incontinence is estimated to affect up to 34% of women with gynecologic cancers. Chemotherapeutic effects on urinary symptoms have been scarcely studied. The aim of our study was to examine the impact of carboplatin/paclitaxel chemotherapy on urinary symptoms. METHODS: This was a prospective cohort study of all women undergoing adjuvant chemotherapy with carboplatin/paclitaxel after their primary debulking surgery for ovarian, fallopian tube, peritoneal, or endometrial cancers performed at a tertiary medical center by board certified gynecologic oncologists. We used validated questionnaires (incontinence impact questionnaire (IIQ-7), medical, epidemiologic, and social aspects of aging (MESA), urogenital distress inventory (UDI-6), the Sandvik severity index, and functional assessment of cancer therapy/GynecologicOncology Group-neurotoxicity (FACT/GOG-Ntx)) to assess the effects of carboplatin/paclitaxel therapy on the incidence and severity of urinary incontinence at three time points during the participants' chemotherapy regimen: start of chemotherapy (pretreatment), during the fifth chemotherapy cycle (mid-cycle), and during the 6-12 week post-chemotherapy visit (post-treatment). RESULTS: We identified 62 women with ovarian, fallopian, peritoneal, and endometrial cancer who received carboplatin/paclitaxel therapy between May 2009 and December 2012 who met all of the inclusion criteria. Analysis of median IIQ-7 scores, across all time points, showed a statistically significant difference (0.0 (0.0 to 4.8), 0.0 (0.0 to 7.1), 0.0 (0.0 to 0.0), p=0.002, respectively). Examining pairwise differences between two treatment points, IIQ-7 pretreatment versus mid-treatment and pretreatment versus post-treatment, did not achieve significance (0.0 (0.0 to 2.4), p=0.13 and 0.0 (0.0 to 0.0), p>0.999, respectively), but the decrease in IIQ-7 mid-treatment versus post-treatment was statistically significant (0.0 (-2.4 to 0.0), p=0.003). Generalized estimating equation model analysis also showed significant changes in both median MESA for urge urinary incontinence (MESA-UUI) and median MESA for stress urinary incontinence (MESA-SUI) across all time points (p=0.003 and p=0.009, respectively). MESA-UUI and MESA-SUI pretreatment versus mid-treatment analysis achieved significance (2.0 (0.0 to 4.0), p=0.003 and 0.0 (0.0 to 2.0), p=0.01, respectively), demonstrating an increase in the incidence of stress urinary incontinence and urge urinary incontinence. There was a statistically significant association between the changes in FACT and UDI-6 scores from pretreatment versus mid-treatment, with a correlation coefficient of 0.37 (95% CI 0.08 to 0.61, p=0.005). CONCLUSION: The study achieved its primary aim in demonstrating an impact of carboplatin/paclitaxel therapy on urinary incontinence severity and suggests if may be a factor leading to new onset or worsening urinary incontinence. As quality of life can be significantly impacted by these chemotherapeutic changes, further investigation is warranted to determine if the effects on urinary incontinence and neuropathy are transient or permanent.

Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort.

OBJECTIVES: The aim of this study was to evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). METHODS: This is a retrospective cohort study comparing all women who underwent laparoscopic and vaginal USLSs at 2 institutions (part of a single training program with procedures performed by 11 fellowship-trained Female Pelvic Medicine and Reconstructive Surgery gynecologic surgeons) between January 2008 and June 2013. RESULTS: A total of 208 patients in the study underwent a USLS, 148 in the laparoscopic group and 60 in the vaginal group. At baseline, there were statistically significant differences between the groups in mean age (50.4 vs 55.3 years, P = 0.008), parity (2.44 vs 2.77, P = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively; P = 0.042).There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.0% vs 10.0%, respectively; P < 0.001). In an analysis evaluating only those ureteral compromises requiring stent placement, the higher rate of ureteral compromise in the vaginal group persisted despite exclusion of those cases requiring only suture removal and replacement (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; P = 0.023).There was a lower median blood loss in the laparoscopic group (137.5 vs 200.0 mL, respectively; P = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; P = 0.025). There were no other significant differences in postoperative complications between the 2 groups. CONCLUSIONS: We found a lower rate of ureteral compromise in the laparoscopic approach to USLS compared with the traditional vaginal approach.

Safety of combined abdominal sacral colpopexy and sigmoid resection with suture rectopexy: a retrospective cohort study.

OBJECTIVES: This study aimed to determine if abdominal sacral colpopexy (ASC) using mesh can be safely combined with sigmoid resection and anastomosis. METHODS: This is a single institution, retrospective chart review of patients who underwent combined ASC and suture rectopexy with sigmoid resection between January 1, 2007, and December 31, 2011. Charts were screened for outcome data and complications related to the placement of synthetic mesh at the time of bowel resection to include readmission and reoperation rates, infection, bowel obstruction, fistula, and mesh erosion. Outcome data for patients receiving combined procedures were compared to 2 separate cohorts of patients as follows: a group that underwent only ASC with polypropylene mesh and a group that underwent only sigmoid resection plus or minus suture rectopexy. The DINDO surgical classification system was used for each cohort to further analyze complications. RESULTS: There were 133 patients in the ASC only group (ASC only), 34 in the combined ASC and sigmoid resection group (Combined), and 27 in the sigmoidectomy plus rectopexy group (Colorectal only). The Colorectal only cohort had a higher rate of postoperative ileus; ASC only 3.8%, Combined 5.9%, Colorectal 22.2% (P = 0.004). There were otherwise no differences in intraoperative and postoperative complications or in the DINDO classification scores. CONCLUSIONS: Abdominal sacral colpopexy with placement of synthetic mesh at the time of sigmoid resection and anastomosis does not seem to increase the rate of intraoperative or postoperative complications.

Intraoperative and postoperative gastrointestinal complications associated with laparoscopic sacrocolpopexy.

OBJECTIVE: This study aimed to quantify the risks of intraoperative and postoperative gastrointestinal (GI) complications associated with laparoscopic sacrocolpopexy and identify possible risk factors. METHODS: A total of 390 medical records were retrospectively reviewed for GI complications. Complications were classified as functional complications [ileus, small bowel obstruction (SBO), and prolonged nausea/emesis] or bowel injury. Nausea/emesis was considered prolonged if these symptoms resulted in a hospital stay of greater than 48 hours, or in readmission. RESULTS: Functional GI complications included 1 ileus, 3 SBOs, and 3 cases of prolonged nausea/emesis. The combined rate for ileus and SBO was 1.0% and the rate of prolonged nausea/emesis was 0.8%. Functional GI complications were associated with prior abdominal surgery (P = 0.048), but there were no differences in age, body mass index, estimated blood loss, or operative time.There were 3 small bowel and 2 rectal injuries for a bowel injury rate of 1.3%. Bowel injury was not associated with prior abdominal surgery (P = 0.071), age, body mass index, estimated blood loss, or operative time. The total reoperation rate for SBO or bowel injury was 0.8%. CONCLUSIONS: The rates of GI complications in laparoscopic sacrocolpopexy are low. Prior abdominal surgery was associated with an increased risk of functional GI complications, but not bowel injury. This information should assist surgeons with preoperative patient counseling.

Commonalities of cerclage-related genitourinary fistulas.

OBJECTIVES: The purpose of this review was to identify common features of cerclage-related genitourinary fistulas. METHODS: A retrospective case series of cerclage-related fistulas was performed. The results were then pooled with available published case reports to identify common factors in these cases. Fistula location, surgical technique, and previous surgical and obstetrical histories were examined. RESULTS: From 2008 to 2011, 5 women were referred with vesicovaginal fistulas after cerclage. Within this series, 4 had prior cervical procedures, 3 had previous cesarean deliveries, and 4 had a McDonald cerclage in the antecedent pregnancy. When pooled with available data in 7 published case reports on cerclage-related fistulas, all 12 fistulas occurred in patients with prior histories of cervical procedures or cesarean deliveries. Specifically, of the 12 patients, 8 [66.7%; 95% confidence interval (CI), 0.39-0.86] had at least 1 prior cerclage and 10 (83.3%; 95% CI, 0.54-0.97) had at least 1 prior cervical surgery. When reported, 81.8% (95% CI, 0.51-0.96) had the McDonald technique used for placement of the current cerclage. CONCLUSIONS: The isolated and pooled findings suggest previous cerclage, any previous cervical procedures, and use of the McDonald technique are common factors in cases of cerclage-related genitourinary fistulas. This information may be useful when evaluating and counseling patients.

Effect of operative technique on mesh exposure in laparoscopic sacrocolpopexy.

OBJECTIVES: To determine if opening the vaginal cuff during laparoscopic sacrocolpopexy influences the rate of mesh exposure. METHODS: A total of 390 medical records were retrospectively reviewed for demographic information, operative technique, and relevant outcomes. RESULTS: Eleven mesh exposures (2.8%) and 14 suture extrusions (3.6%) were found, none involving visceral organs. Mesh exposure was more common when the vaginal cuff was opened, either during hysterectomy or when allowing transvaginal attachment of mesh in patients with a prior hysterectomy (4.9% vs 0.5%; relative risk [RR], 9.0, P = 0.012). In cases where concomitant hysterectomy was performed, a higher mesh exposure rate was seen in open-cuff hysterectomy (total vaginal hysterectomy/laparoscopically assisted vaginal hysterectomy) compared to supracervical hysterectomy (4.9% [9/185] vs 0% [0/92]; P = 0.032). Mesh exposure was more common when the mesh was sutured laparoscopically compared with transvaginally in patients undergoing open-cuff hysterectomy (14.3% [5/35] vs 2.7% [4/150]; RR, 5.4; P = 0.013). Permanent suture extrusion was significantly associated with laparoscopic versus transvaginal suturing of mesh (5.6% vs 0.6%; RR, 8.8; P = 0.010). Five patients underwent reoperation for mesh exposure, whereas most suture extrusions were asymptomatic; and all were managed nonsurgically. CONCLUSIONS: We found that preserving the integrity of the vaginal cuff led to a lower incidence of mesh exposure in patients undergoing laparoscopic sacrocolpopexy. When hysterectomy is indicated, a supracervical technique should be strongly considered as the mesh exposure rate was significantly lower. If removal of the cervix is indicated, the risk for mesh exposure remains low and should not preclude total hysterectomy, though transvaginal mesh attachment may be preferable.

A pilot study on vaginally assisted laparoscopic sacrocolpopexy for patients with uterovaginal prolapse.

OBJECTIVES: : The primary objective of this pilot study was to compare the short-term anatomic outcomes and complication rates of vaginally assisted laparoscopic sacrocolpopexy (VALS) with those of conventional laparoscopic sacrocolpopexy (LS) in patients undergoing concurrent hysterectomy. The secondary objective was to compare operative times of the 2 different techniques. METHODS: : This is a retrospective pilot study comparing VALS-a method using transvaginal mesh attachment to the vaginal apex-to conventional LS in patients undergoing concurrent hysterectomy. RESULTS: : Forty-four women underwent VALS, and 26 women underwent LS. There was no significant difference in intraoperative complication rates (2.3% vs 3.8%, not statistically significant), postoperative complication rates (4.5% vs 0.0%, P = 0.526), mesh extrusion rates (2.3% vs 0%, not statistically significant), or postoperative pelvic organ prolapse quantification scores. The mean total operative time was 55 minutes shorter for the VALS group (215.2 [SD, 41.0] minutes) than the LS group (269.7 [SD, 55.6] minutes; P < 0.001). CONCLUSIONS: : There was no significant difference in short-term anatomic outcomes or complication rates between groups. Vaginally assisted LS was associated with significantly shorter operative times than conventional LS.

De novo stress incontinence and pelvic muscle symptoms after transvaginal mesh repair.

OBJECTIVE: We sought to determine the rate of de novo stress incontinence, pelvic muscle symptoms, mesh exposure, visceral injury rate, and recurrent prolapse after transvaginal mesh repair. STUDY DESIGN: We conducted a retrospective review of 335 consecutive women with stage II or worse vaginal prolapse who underwent Prolift (Ethicon, Somerville, NJ) between July 7, 2005 and Jan. 31, 2008. RESULTS: In all, 71% underwent total Prolift, 20% anterior, and 8% posterior alone. Average age was 62 years and mean follow-up was 8 months. The intraoperative visceral injury rate was 6.6%, mesh exposure rate was 3.8%, and recurrent failure rate was 5.2%. The postoperative de novo stress incontinence rate was 24.3%. In this series, 18% of women had pelvic muscle symptoms postoperatively; 74% of these resolved within 6 months with conservative management. CONCLUSION: After Prolift, surgeons can expect a low rate of recurrent prolapse and mesh exposure. However, pelvic muscle dysfunction and de novo stress incontinence will be encountered postoperatively in a moderate number of women.

Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse.

OBJECTIVES: Our purpose was (1). to report long-term objective and subjective outcome data after total colpocleisis with high levator plication and (2). to compare operative morbidity of total colpocleisis in patients with prior versus concurrent hysterectomy. STUDY DESIGN: The medical records of patients who underwent total colpocleisis with high levator plication between August 1, 1988, and December 31, 2000, were retrospectively reviewed. Patient characteristics, operative data, and objective outcome measures including pelvic organ prolapse staging measurements were obtained from subject records. Subjective outcome measures were obtained by a standardized telephone survey. A t test was used to compare continuous variables between patients who underwent prior versus concurrent hysterectomy. The Fisher exact test was used to test for association between patient group and each categorical variable. RESULTS: During the 12-year study period, 92 subjects underwent total colpocleisis with high levator plication. Of the 92 subjects, 90 (97.8%) underwent concurrent operations and 37 (40.2%) underwent simultaneous hysterectomy. With objective cure defined as absence of prolapse to the hymen, 90 subjects (97.8%) were objectively cured after a median follow-up of 12 months (range, 0-64 months). Of 62 subjects available for telephone follow-up, 56 (90.3%) reported being satisfied or very satisfied with how the surgery cured their prolapse after a median follow-up of 24 months (range, 13-161 months). Concurrent hysterectomy was associated with statistically significant increases in absolute change in hematocrit (9.5% without vs 11.9% with hysterectomy) and transfusion requirement (12.7% without vs 35.1% with hysterectomy). There was no significant difference in surgical complications between groups. CONCLUSION: Total colpocleisis is an effective operation for the treatment of advanced pelvic organ prolapse. Concurrent hysterectomy is associated with higher blood loss and transfusion requirements.

Urethral adenocarcinoma associated with urethral diverticulum in a patient with progressive voiding dysfunction.

Urethral adenocarcinoma associated with urethral diverticulum is a rare condition that requires a high index of suspicion to ensure early diagnosis and appropriate therapy. The development of urethral stenosis in a patient with a urethral diverticulum warrants early biopsy to rule out a malignant lesion.