Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison.

UNLABELLED: Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison. PURPOSE: To determine if local injection, prior to incision with lidocaine plus epinephrine (L + E) influences the rate of mesh exposure in the early postoperative period following synthetic mesh augmented vaginal reconstructive surgery (MAVR). METHODS: We performed a chart review over an 18-month period of patients who underwent MAVR. The presence of mesh exposure at the 3-month postoperative visit, demographic data and whether or not L + E was used to hydrodissect was recorded. Statistical analysis was performed to determine whether hydrodissection influenced erosion rates. RESULTS: A total of 143 meshes were placed, hydrodissection with L + E was used in 78 cases and was not in the remaining 65 cases. There were 10 (7.0% 10/143) total erosions at the 3-month postoperative visit, 6 (7.7%; 6/78) in the group that got L + E and 4 (6.2%; 4/65) in the group that did not get local injection. This difference was not significant (p = 0.740, OR 1.54 95% CI 0.41-5.76). There was no difference between the two groups in terms of age, presence of diabetes, concurrent incontinence repair or estimated blood loss. CONCLUSION: Mesh exposure is a known complication of MAVR. Our study suggests that local injection with L + E prior to vaginal surgery does not influence exposure rates.

A multicenter prospective trial evaluating fetal bovine dermal graft (Xenform® Matrix) for pelvic reconstructive surgery.

BACKGROUND: A prospective multicenter clinical study was performed to evaluate the safety and efficacy of a bovine dermal graft (Xenform® Matrix, Boston Scientific, Natick, MA, USA) during vaginal reconstructive surgery. METHODS: Forty-five women with ICS stage 2 or higher pelvic organ prolapse (POP) were enrolled at 4 centers. POP-Q, pelvic floor function (PFDI-20), sexual function (PISQ-12), and patient satisfaction tools were used to assess subjects at baseline, and at 2 and 6 weeks, and 3, 6 and 12 months post surgery. The significance of symptom score changes at 6 months and 1 year were determined by the t-test for paired data. Forty-three of the 45 patients completed the 12 month study. RESULTS: The majority of the subjects had cystocele (98%) and/or rectocele (84%) defects at study entry. At 12 months, 74% of the defects had improved to a stage 0 or 1. Mean PFDI-20 scores improved by 72% (p < 0.001) at 12 months, and PISQ-12 scores were maintained during the follow-up period indicating no decline in sexual function. Three subjects experienced one serious adverse event each; one of the adverse events (constipation) was deemed by the study physician to be unrelated to Xenform®. One subject had severe pyelonephritis resulting in dialysis. This subject had a previous history of pyelonephritis, sepsis and acute renal failure. The third subject had a reported recurrent cystocele of moderate severity, possibly related to the device. No graft related erosions or pain lasting more than 30 days were reported. No subjects withdrew due to an adverse event. CONCLUSION: This study is the first to investigate the use of Xenform® Matrix in vaginal reconstructive surgery among patients with POP. Significant improvement was maintained at 12 months utilizing both objective and subjective assessment tools, confirming the safety and efficacy of this material in vaginal surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01244165.

Characteristics of physicians who choose fellowship training in obstetrics and gynecology.

INTRODUCTION: : To determine the attributes and motivation of physicians who pursue fellowship training in the subspecialties of Obstetrics and Gynecology (Ob/Gyn). METHODS: : We surveyed current fellows and recent graduates from the ABOG recognized subspecialties in Ob/Gyn. Demographics and reasons for pursuing fellowship training were obtained. Significant differences between and among groups were determined using the Mann-Whitney U test and Pearson χ test. RESULTS: : Forty-two percent of those sent a survey responded. The majority were between ages 30 to 35 (65.7%), female (60.5%), married (74.5%), and White (68.8%). Over 55% in each subspecialty cited interest in subject area as the primary reason for choosing their fellowship. CONCLUSION: : Interest in subject remains the primary motivation for the majority of physicians choosing subspecialty fellowship training in Ob/Gyn. There is considerably more variation regarding what physicians' secondary motivation is and these reasons appear to vary according to the particular subspecialty.

Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs.

INTRODUCTION AND HYPOTHESIS: Our objective was to establish the overall graft erosion rate in a synthetic graft-augmented repair 3 months postoperatively. METHODS: A retrospective chart review was performed on a cohort of subjects who underwent mesh-augmented vaginal reconstructive surgery during an 18-month period. We defined graft erosion as exposure of any mesh upon visual inspection of the entire vagina at the 3-month postoperative visit. Statistical tests performed to evaluate proportional differences were the Pearson chi square and Fisher exact tests. Independent t test was performed to compare mean differences. RESULTS: A total of 124 grafts were implanted. The overall erosion rate was 11.3%. There was a significantly lower erosion rate when using "commercial kits" vs. our traditional repairs (1.4% [one out of 69] vs. 23.6% [13 out of 55]; p < 0.001). CONCLUSIONS: Our study demonstrates a significantly lower erosion rate when using a "commercial kit" to repair pelvic organ prolapse compared to our traditional synthetic graft-augmented repair.

Latent pelvic tuberculosis reactivating in a postmenopausal woman: a case report.

BACKGROUND: Tuberculosis most often affects the pulmonary system; however, 8-15% of cases infect the genitourinary system. The primary treatment of uterine tuberculosis is medical therapy, and only when that fails is surgical intervention warranted. CASE: A 75-year-old woman presented with chronic back pain and fatigue. She had been on prednisone for 9 years for autoimmune hepatitis and had earlier exposure to tuberculosis. Evaluation led to the diagnosis of uterine tuberculosis. The patient was unable to tolerate a full course of antituberculin therapy, so she underwent an abdominal hysterectomy and bilateral salpingo-oophorectomy. CONCLUSION: We believe the patient had latent uterine tuberculosis that was reactivated from her chronic steroid use. If she had a purified protein derivative test prior to the start of prednisone therapy, latent tuberculosis may have been diagnosed and treated before she developed a clinically active infection.

A menopausal woman with mullerian agenesis, a leiomyoma, an inguinal hernia, and cystadenofibromas.

BACKGROUND: Müllerian agenesis, the second most common cause of primary amenorrhea, affects 1 in 4,000 to 10,000 women. Although the majority of these women have complete absence of the uterus, a small percentage can have a rudimentary uterus. CASE: A menopausal nulligravida with known müllerian agenesis developed a large pelvic mass and an inguinal hernia. The patient underwent an exploratory laparotomy, which revealed a large leiomyoma growing from a small rudimentary uterus, an indirect inguinal hernia, and bilateral benign serous cystadenofibroma. CONCLUSION: Women with müllerian agenesis and rudimentary uteri can develop gynecologic pathology similar to women with normal genital tracts.