Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele.

OBJECTIVE: This study compared 3 surgical methods of prophylaxis against enterocele formation employed at the time of vaginal hysterectomy. STUDY DESIGN: One hundred consecutive women undergoing total vaginal hysterectomy for various reasons were randomly assigned to have 1 of 3 surgical methods applied to the posterior superior aspect of the vagina for prophylaxis against enterocele formation. The first procedure involved closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the midline in a vaginal Moschcowitz-type operation. The second procedure was a McCall-type culdeplasty to obliterate the cul-de-sac, plicate the uterosacral-cardinal complex, and elevate any redundant posterior vaginal apex. The third technique used only the peritoneum to close the cul-de-sac, allowing passive movement of the uterosacral-cardinal complex to the midline, no obliteration per se, and no elevation of the posterior vagina. Postoperative findings on pelvic examination were evaluated at 6 weeks, 3 months, and 1, 2, and 3 years. Statistical analysis was performed with the chi2 test of independence. RESULTS: At 6 weeks' follow-up and at 3 months' follow-up there were no prolapses involving the posterior superior segment of the vagina. At 1 year of follow-up 11 patients had stage 1 or 2 posterior superior segment prolapse. At 2 years' follow-up this number was 16. At 3 years' follow-up the McCall-type method was statistically better (chi2 = 11.27 with 2 degrees of freedom, P =. 004) than the other 2 in preventing postoperative enterocele (n = 2 of 32 with McCall-type procedure, n = 10 of 33 with vaginal Moschcowitz-type procedure, and n = 13 of 33 with peritoneal closure only). CONCLUSION: When applied at the time of vaginal hysterectomy the McCall-type culdeplasty is superior to a vaginal Moschcowitz-type procedure and to simple peritoneal closure in preventing subsequent enterocele.

The functional anatomy of the urethra: role of the pubourethral ligaments.

OBJECTIVE: This clinical study examines and defines the functional anatomy of the urethra as it relates to the Valsalva and Kegel maneuvers and to urethral stability. STUDY DESIGN: Dissection of embalmed cadavers and examination of 60 patients were performed to study adjunct structures in urethral stability. Provocative maneuvers (Valsalva and Kegel) were used in all 60 patients. Urethral prolapse was graded with use of the international Continence-Society classification. RESULTS: Cadaveric dissection confirmed the structural anatomy of the pubourethral muscles and ligaments. Physical examination in 30 patients revealed a lack of urethral stability in all patients with stress urinary incontinence. In 30 patients acting as normal controls, no urinary incontinence was present, and all maintained urethral stability with provocation. The urethrovesical junction was mobile in all patients in performing a Valsalva maneuver. CONCLUSION: Intact pubourethral ligamentous and muscular attachments aid in stabilizing the urethra to its normal anatomic position. This helps maintain continence.

Pubic bone suburethral stabilization sling for recurrent urinary incontinence.

A suburethral sling anchored to the posterior-inferior aspect of the pubic bone with bone screws placed transvaginally is described for recurrent urinary incontinence. The technique involves placing a suburethral patch of a synthetic fiber at the junction of the upper one-third and lower two-thirds of the urethra and securing it by titanium bone screws to the posterior-inferior pubis for site-specific urethral support and stabilization of normally positioned continence anatomy. The procedure was performed from August 1990 through December 1991 in 27 patients with recurrent stress urinary incontinence after previous urinary incontinence surgery, of whom 25 patients were followed yearly until August 1994. None of these 25 patients have had a recurrence as of August 1996. The initial success of the pubic bone suburethral stabilization sling merits further study for the cure of urinary incontinence in patients with a hypermobile urethra or low-pressure urethral conditions.

Guidelines to determine the route of oophorectomy with hysterectomy.

OBJECTIVES: Our purpose was to determine whether there is adequate visibility and access for transvaginal oophorectomy in most patients and the success rate of the transvaginal approach. The final goal was to establish objective guidelines for choosing the route of oophorectomy with hysterectomy. STUDY DESIGN: Patients underwent laparoscopy-assisted vaginal hysterectomy (n = 91) or vaginal hysterectomy (n = 875). Ovarian removal, either unilateral (n = 97) or bilateral (n = 187), was carried out for clinical or prophylactic reasons. The accessibility of the ovaries for transvaginal removal was assessed by stretching the infundibulopelvic ligament and grading the position of the ovaries from 0 (no descent) to III (descent past the hymenal ring with traction). RESULTS: In 158 patients transvaginal bilateral oophorectomy was performed without laparoscopic assistance. In another 29 patients bilateral transvaginal oophorectomy was performed with laparoscopy-assisted vaginal hysterectomy, and prophylactic bilateral oophorectomy by the transvaginal route was successful in all but 1 of 143 patients with ovaries of grade I or higher. In 20 patients laparoscopic lysis of adhesions was necessary to permit transvaginal oophorectomy. Ninety-seven patients underwent transvaginal unilateral oophorectomy, 74 with conventional vaginal hysterectomy and 23 with laparoscopy-assisted vaginal hysterectomy. Among the patients not having oophorectomy, all ovaries had sufficient mobility to have been removed transvaginally. CONCLUSION: Good surgical practice dictates that visibility and accessibility be the primary criteria for selecting the route of oophorectomy with hysterectomy. In most patients the ovaries are visible and accessible to transvaginal removal.

Anterior vaginal wall culdeplasty at vaginal hysterectomy to prevent posthysterectomy anterior vaginal wall prolapse.

OBJECTIVE: The purpose of our study was to evaluate a surgical technique we have developed that, when used at vaginal hysterectomy, helps prevent posthysterectomy anterior vaginal segment (wall) prolapse. STUDY DESIGN: This modified surgical procedure was used in 966 consecutive vaginal hysterectomies performed from January 1989 through December 1994. Patients returned at 1, 3, and 12 months and annually thereafter for follow-up. The longest follow-up period to date is 5.5 years. RESULTS: Of the 925 patients in our study followed up for > or = 1 year, 908 (98.1%) retained excellent anterior vaginal support. Symptomatic anterior vaginal segment prolapse occurred in 12 patients (1.3%), and asymptomatic prolapse, with the anterior vaginal wall descending less than halfway from the ischial spines to the hymen, occurred in 5 (0.5%). None of the 42 patients followed up for <1 year has had evidence of prolapse. CONCLUSION: This procedure is an acceptable method to help prevent posthysterectomy anterior vaginal segment prolapse.

Successful pregnancies and vaginal deliveries after sacrospinous uterosacral fixation in five of nineteen patients.

OBJECTIVE: We sought to determine whether sacrospinous uterosacral ligament fixation restores the uterus to its normal anatomic position, preserving uterine function and allowing future childbearing. STUDY DESIGN: This study was undertaken at two separate medical centers. Women with symptomatic uterovaginal prolapse who desired either uterine preservation or future childbearing were included. RESULTS: We successfully performed sacrospinous fixation of the uterosacral ligaments in 19 patients. Five patients have since been delivered vaginally (for a total of six deliveries). Normal anatomic restoration was accomplished in all but one patient. CONCLUSIONS: Sacrospinous uterosacral ligament fixation is an acceptable surgical means to care for symptomatic uterovaginal prolapse in women desiring uterine preservation or future childbearing. To our knowledge, this is the first report of successful pregnancies and vaginal deliveries after sacrospinous uterosacral fixation.

Role of the uterosacral-cardinal ligament complex in protecting the ureter during vaginal hysterectomy.

OBJECTIVE: To determine the surgical anatomy of the ureter during vaginal hysterectomy. METHOD: Sixty patients undergoing vaginal hysterectomy were studied. All patients had moderate or severe uterovaginal prolapse or complete procidentia. Ureteral position was noted after traction and cutting of each uterosacral-cardinal ligament complex. RESULT: In the 40 patients with moderate or severe uterovaginal prolapse, the ureter did not move significantly when traction was applied to the cervix and there was no upward retraction on the bladder. When the uterosacral-cardinal ligament complex was cut, with forceful traction on the cervix and upward bladder retraction, the ureter was elevated from the operative field. The same was true for those 20 patients with procidentia after cutting the cardinal ligaments. CONCLUSION: Traction and cutting of the cardinal ligaments are the chief factors affecting movement of the ureter during vaginal hysterectomy; this action protects the ureter. Added protection by the cardinal ligament occurs with bladder retraction.

Reconstructive procedures for the gynecologic surgeon.

In this article are discussed several minor reconstructive pelvic procedures that should be a part of the gynecologic surgeon's armamentarium, specifically the following: Z-plasty, full-thickness skin grafting, skin flaps, W-plasty, and transposition skin flaps. These procedures are essential in both primary reparative and reoperative surgery. These procedures are widely used in other surgical specialties and can be adapted for use in gynecologic surgery.

Lead levels among pregnant women in Hennepin County.

The purpose of this study was to determine the blood lead levels (Pb-B) of urban pregnant women with low incomes and/or living in areas with heavily traveled roads, dilapidated housing, and industrial plants. We measured blood lead in 1,055 pregnant Minneapolis-area women at entry to prenatal care and in one-third of the sample during the second half of pregnancy. The mean Pb-B level of the first sample (n = 1,055) was 1.83 +/- 1.83 micrograms/dL; of the second sample (n = 375), 1.99 +/- 1.92 micrograms/dL. Only one woman had a Pb-B level greater than 12.0 micrograms/dL, which was the result of occupational exposure. The low lead levels found in this study indicate that it is not necessary to routinely screen pregnant women for elevated Pb-B levels in our geographic area. Rather, women should be screened via an environmental questionnaire to ascertain the risk of lead exposure.

Sacrospinous fixation--should this be performed at the time of vaginal hysterectomy?

A sensible individualized approach should be applied to every patient undergoing transvaginal surgery for benign disease. This approach should attempt to correct every defect present in the pelvic supports. Uterovaginal prolapse is the result rather than the cause of genital prolapse. Not every vaginal hysterectomy should be treated like a cystocele-rectocele repair. Instead, every defect of the endopelvic fascial support should be evaluated in a patient both before and during surgery. As a result of these evaluations, more than just a hysterectomy and an anterior and posterior colporrhaphy may be performed. In a case in which a patient is found to have more than one defect at the time of examination, sacrospinous fixation of the vaginal apex at the time of transvaginal hysterectomy may be indicated. In the office, the patient can be examined in the supine and standing positions, both with and without Valsalva's maneuver, to determine if moderate to severe uterovaginal prolapse exists. Sacrospinous fixation should be performed in those cases as an adjunct to other steps taken to prevent postthysterectomy prolapse.

A case of Rh isoimmunization: should threatened first-trimester abortion be an indication for Rh immune globulin prophylaxis?

Despite the recommended 28 weeks' gestation antenatal, postnatal, and postabortion prophylaxis with Rh immune globulin, residual Rh immunization still occurs in Rh-negative women. We describe a patient whose history suggests development of an anti-D antibody after first-trimester bleeding. To our knowledge, this is the first such case reported in the English literature.

Sacrospinous ligament fixation at the time of transvaginal hysterectomy.

Sacrospinous ligament fixation of the vagina was performed on 48 of 135 patients at the time of transvaginal hysterectomy. All 48 patients in the group had at least moderate or severe uterovaginal prolapse and symptomatic pelvic relaxation, which is described herein. In five patients cystoceles developed, in two patients rectoceles developed, and one patient has had vault prolapse subsequent to surgery. Morbidity was minimal. Postoperative results indicate that sacrospinous ligament fixation of the vagina can be a useful adjunctive procedure when performed at the time of vaginal hysterectomy.

Laparoscopy-assisted vaginal hysterectomy.

Intraoperative laparoscopy was used to evaluate pelvic pathology in 46 patients who had been anesthetized for abdominal hysterectomy. Because traditional indicators--clinical history, pelvic examination, and ultrasound studies--suggested the presence of more serious pelvic pathology, these patients were considered poor candidates for vaginal hysterectomy. Laparoscopic findings, however, revealed that 42 of the 46 (91%) could undergo uncomplicated vaginal surgery (which they did). Laparoscopy-assisted hysterectomy is recommended as an additional method of investigation in order to improve diagnostic accuracy and minimize surgical risk while allowing more frequent selection of the vaginal approach to hysterectomy.

Early closure of posthysterectomy vesicovaginal fistulas.

This report presents the results of early closure of 11 posthysterectomy vesicovaginal fistulas, using a modified transvaginal approach. Early repair of this complication is acceptable and probably desirable. Review of the English literature indicate that these 11 patients comprise the single largest series of patients treated by early vaginal repair.

Methods of vaginal cuff closure during vaginal hysterectomy.

Over a 2.8-year period, I did 112 vaginal hysterectomies using five different techniques of cuff closure to examine the preservation of vaginal length associated with each closure. I conclude that all five methods are acceptable as long as there is proper vault support. Morbidity was minimal, vaginal depth was retained, and there were no deaths.

Increased amniotic acetylcholinesterase activity with a fetus papyraceus and aplasia cutis congenita.

A case of an infant with aplasia cutis congenita, a fetus papyraceus, abnormal maternal serum alpha-fetoprotein (MSAFP), elevated amniotic alpha-fetoprotein, and positive amniotic acetylcholinesterase activity represents an uncommon abnormality. Such a case came to our attention as a result of MSAFP screening. The delivery of a neurologically intact infant in the presence of amniotic acetylcholinesterase activity is described.

Preventing vault prolapse and enterocele after vaginal hysterectomy.

In this paper I describe a modified surgical technique for vaginal hysterectomy designed to prevent posthysterectomy vaginal prolapse and enterocele. Of the 112 vaginal hysterectomies done by this method over a 2.8-year period, none has resulted in prolapse.