Analysis of surgical complications and patient outcomes in a residency training program.

OBJECTIVES: This study compares surgical complications and patient outcomes between pelvic reconstructive surgery performed by an experienced surgeon (group 1) and those performed by resident physicians with the senior surgeon assisting and teaching (group 2). STUDY DESIGN: During a 5-year interval, 310 consecutive women underwent vaginal prolapse repair. Demographic, historic, and preoperative physical examination variables were compared. Intraoperative and postoperative outcomes were also compared. RESULTS: Patients operated on by the senior surgeon (Bob L. Shull) were thinner (group 1 vs group 2: 25.8 kg/m2 vs 27.1 kg/m2; P =.014), more often had prior prolapse or incontinence procedures (55% vs 33%; P <.001), and required shorter operating times (124 minutes vs 140 minutes; P =.002). The senior surgeon's patients differed from the resident physicians' patients with regard to stage of pelvic organ prolapse. No differences were observed for patient age (P =.51), estimated blood loss (P =.50), urologic complications (P =.59), and hospital stay (P =.25). The durability of the repairs was not different between the groups. CONCLUSIONS: We have demonstrated that in a tertiary referral practice resident surgeons can be taught to perform complex vaginal surgery with the only observed disadvantage being a slightly prolonged operative time.

A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments.

OBJECTIVE: The objectives of this study were (1) to describe a group of women with pelvic organ prolapse associated with apical loss of support through grading with the Baden-Walker halfway system before, during, and after the corrective operation, (2) to describe the operative repair of the support defects, (3) to report the morbidity associated with the operative repair, and (4) to assess the durability of the repair at each site. STUDY DESIGN: Between January 1, 1994, and December 31, 1998, a total of 302 consecutive women with apical and associated other support defects were evaluated before, during, and after the corrective operation by the senior author (Bob L. Shull). All patients underwent transvaginal reconstructive surgery with native tissue. Two hundred eighty-nine patients (96%) returned for at least one postoperative visit, and they constitute the group used for the follow-up data. Perioperative morbidity was considered to include hemorrhage necessitating homologous blood transfusion, visceral injury, neurologic impairment, or death. Durability was assessed by means of life-table analysis for each of 5 sites in the vagina. RESULTS: All patients had preoperative or intraoperative evidence of grade 1 or greater apical loss of support of and at least one other site of pelvic organ prolapse. Two hundred eighty-nine patients (96%) returned for at least one postoperative visit. Two hundred fifty-one patients (group 1, 87%) had optimal anatomic outcomes, with no persistent or recurrent support defects at any site. Thirty-eight patients (group 2, 13%) had one or more sites with at least grade 1 loss of support during the follow-up interval. Twenty-four of these 38 patients had grade 1 defects that were detectable only on careful pelvic examination. Fourteen of these patients (5%) had grade 2 or greater persistent or recurrent support defects. The anterior segment (bladder) was the site with the most persistent or recurrent support defects, which means that it was the site of the least durable repair. The urethra and cuff had the most durable repairs. Morbidity included a 1% transfusion rate, a 1% ureteral injury or ureteral kinking rate, and a 0.3% postoperative death rate. CONCLUSION: Careful preoperative and intraoperative evaluation of pelvic support defects and the use of native connective tissue and uterosacral ligaments are associated with excellent anatomic outcomes. The durability of the surgical correction varies according to the individual site of repair and the duration of postoperative follow-up.

Pelvic organ prolapse: anterior, superior, and posterior vaginal segment defects.

Pelvic organ prolapse is a complex entity that potentially involves not only poor support for multiple sites in the vagina but also the function of the urethra, bladder, and anorectum, as well as sexual function. We must provide a comprehensive approach to the evaluation and management of women with pelvic organ prolapse and must critically review the assessment of surgical management.

The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.

This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.

The squirrel monkey as an animal model of pelvic relaxation: an evaluation of a large breeding colony.

OBJECTIVE: Findings of pelvic relaxation have been reported in up to 50% of older adult female squirrel monkeys. To evaluate further the potential use of the squirrel monkey as an animal model of pelvic relaxation, we objectively observed and described the perineal findings of 160 adult females. The aim of this study was to examine the relationship of perineal findings to age and parity, factors thought to predispose women to pelvic relaxation. STUDY DESIGN: The urethra, cervix, and anterior and posterior segments of the vagina were evaluated. The degree of support loss at each site was documented. Genital measurements were obtained by previously reported methods. The findings were tested for association with elements of obstetric history, age, and subspecies. RESULTS: The females represented three subspecies and ranged from 3 to 17 years old with parities of 0 to 10. The proportion of females with normal support was inversely related to increasing parity and age. Although birth weights, frequency of dystocia at term, and requirement for cesarean section did not differ significantly between females with and without evidence of prolapse, animals with multiple sites of prolapse tended to have infants with higher birth weights. Animals without prolapse were significantly younger and less likely to have been delivered of a term infant (p < 0.001). Subspecies differences unrelated to age or parity were found for each of the genital measurements. Differences were also found between animals with normal perineal findings and those with findings of prolapse. Animals with prolapse had shorter perineal bodies (p < 0.001), greater genital hiatal ratios (p < 0.001), and wider genital hiatal measurements (p < 0.001). Females with abnormal pelvic findings were of increased parity (4.0 vs 1.6, p < 0.001) and age (9.4 vs 6.3 years, p < 0.001) compared with those normal pelvic findings. CONCLUSION: Analysis of genital prolapse in a large population of breeding squirrel monkeys demonstrated an association of loss of pelvic support with age and parity. A tendency for loss of support at multiple sites was associated with obstetric complications. These observations support continuing investigation into the nature and cause of spontaneous pelvic relaxation in this species and support the potential use of this nonhuman primate as an animal model.

The squirrel monkey: an animal model of pelvic relaxation.

OBJECTIVE: Casual observations of pelvic prolapse have previously been made in adult female squirrel monkeys. We objectively observed and described the pelvic findings of the adult females in our colony to evaluate their potential as an animal model for studies of pelvic relaxation. STUDY DESIGN: Subsets of a group of 28 adult female squirrel monkeys were examined on three separate occasions and photographed to document perineal findings. Four areas of loss of support in the vagina were described, including the urethra, anterior segment, cervix, and posterior segment. The degree of loss of support at each specific site was documented. Also, three measurements were obtained from each animal, including the distance from the base of the clitoris to the posterior edge of the perineal body and the length and width of the introitus. The length of the perineal body was calculated. RESULTS: Fifty percent of the animals had at least one site of pelvic prolapse at rest or on straining. With straining 50% had urethral prolapse, 21% had anterior segment prolapse, and 11% had posterior segment prolapse. None of the animals had evidence of cervical prolapse. Of the animals with findings of pelvic relaxation, 43% had combined prolapse at two or more sites. Of the measurements obtained, only the width of the introitus was significantly different between the group of normal animals and those found to have pelvic prolapse (p < 0.0005). CONCLUSION: On the basis of observations of our colony of squirrel monkeys, a significant number of animals demonstrated findings of pelvic support loss with defects similar to those observed in humans. Although limitations to some techniques of evaluation and surgical intervention exist, the squirrel monkey is an animal model that may provide new opportunities for basic investigation of the pathophysiologic features and the management of pelvic relaxation.

Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome.

OBJECTIVES: The objectives of this study were to describe a group of women with prolapse of the anterior vaginal segment associated with bilateral paravaginal defects, to report the morbidity associated with the operative repair, and to analyze the results of preoperative and postoperative pelvic support defects in five vaginal sites. STUDY DESIGN: Between June 1, 1988, and Nov. 3, 1993, 62 consecutive women with prolapse of the anterior vaginal segment associated with bilateral periurethral and perivesicle support defects and other coexisting pelvic support defects were treated by paravaginal repair done via the vagina and total pelvic reconstruction. Site-specific analysis of support for the urethra, bladder, cervix or cuff, cul-de-sac, and rectum was performed preoperatively, 6 weeks postoperatively, and longitudinally to assess the anatomic outcome of surgery. Perioperative morbidity was defined as hemorrhage requiring homologous blood transfusion, pelvic nerve injury, deep venous thrombosis, visceral injury, or infection. RESULTS: One hundred percent of the study patients had preoperative evidence of bilateral paravaginal defects, and 87% had a prolapse of the anterior segment that was halfway to completely outside the hymen. Seven patients experienced perioperative morbidity none of which was unique to this procedure. Fifty-six patients have been followed up a mean of 1.6 years postoperatively. In four, anterior segment defects have developed to or through the hymen, although none is as large as the preoperative defect and none has required further surgery to date. In one patient a postoperative defect developed in the cul-de-sac extending to the hymen; she has had the defect repaired and has been followed up 1.7 years with no support defects. CONCLUSION: Paravaginal repair performed transvaginally is a safe, effective method of management of prolapse of the anterior vagina associated with paravaginal defects. Coexisting support defects that require specific identification and repair can also be managed vaginally.

Vaginal pessaries and their use in pelvic relaxation.

To evaluate the therapeutic usefulness of pessaries in patients with pelvic relaxation, a retrospective study was performed identifying 107 patients who had been fitted with a pessary for symptomatic pelvic relaxation. Of this group, 101 returned or were available for follow-up. Ninety-one had at least one pelvic organ protruding to or beyond the hymen. Specific reasons for using the pessary are cited. Group 1 included 19 patients who were thought to be medically unfit for surgery. Twenty-one percent of this group died within one year of their evaluation for pelvic relaxation. Group 2 was composed of 24 patients who chose to use the pessary only temporarily while awaiting a suitable time for surgery. Group 3 consisted of 58 patients who were offered the option of definitive surgical repair but initially declined. Fifty of the 101 patients have continued to use the pessary. Twenty-six had repairs, and four have died. Only 21 patients have discontinued the pessary, had no surgical repair and thus continue without treatment of their pelvic relaxation. No major complications were associated with use of the pessary.

Bilateral attachment of the vaginal cuff to iliococcygeus fascia: an effective method of cuff suspension.

OBJECTIVE: The objective of this study was to determine the anatomic success, defined as no persistent or recurrent support defects, of suspension of the vaginal cuff to iliococcygeus fascia. STUDY DESIGN: Forty-two women treated by suspension of the vaginal cuff to iliococcygeus fascia and repair of coexisting pelvic support defects between March 19, 1987, and June 11, 1992, had site-specific analysis of pelvic support performed preoperatively and at consecutive postoperative visits. The findings at the 6-week postoperative visit and subsequent visits were compared for support of the vaginal cuff and additionally for the urethra, bladder, cul-de-sac, and rectum. RESULTS: Two patients (5%) have had recurrence of their cuff prolapse during follow-up, one of whom required further surgery. She also had recurrence of an inguinal hernia that had been repaired at the original surgery. The other patient who had had five previous pelvic procedures developed asymptomatic prolapse of the cuff halfway to the hymen. Six additional patients have had loss of support at other sites in the follow-up period, one of whom had repeat surgery. CONCLUSION: Ninety-five percent of women experienced no persistence or recurrence of cuff prolapse 6 weeks to 5 years after the procedure.

Preoperative and postoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction.

OBJECTIVES: The objectives of this study were to identify factors that predict long-term success, defined as the absence of anatomic defects, in women undergoing pelvic reconstruction and to identify which defects most frequently persist or recur. STUDY DESIGN: Eighty-one women treated by sacrospinous ligament suspension and pelvic reconstruction between 1984 and 1990 had site-specific analysis performed preoperatively and at consecutive postoperative visits. The findings at the 6-week postoperative visit and subsequent visits were compared for each of five sites: urethra, bladder, cuff, cul-de-sac, and rectum. RESULTS: The Fisher exact test showed that patients with no support defects at the 6-week visit were less likely to require subsequent repair than patients who had any defect at that visit (p = 0.003). Thirteen patients with subsequent or persistent cystoceles had no bladder repair performed at the time of the study procedure. However, even with repair the bladder was the most likely site for persistence or recurrence. CONCLUSION: Absence of any pelvic support defect at the 6-week postoperative visit is associated with a 3% likelihood that the patient will require subsequent reconstructive surgery within 2 to 5 years. The anterior segment provides the greatest challenge to restoration of normal anatomy.

Urologic surgical techniques.

Surgery for incontinence, other than genuine stress incontinence, is a small part of the general gynecologist's practice. He or she must maintain a high index of suspicion for diverticula and fistulae. Included here are several good review articles that outline the state of the art and include classic references in the bibliography. Patients with cancer with a genitourinary fistula and incontinence may be managed in a variety of ways. Percutaneous nephrostomy and occlusion of the distal ureter may be an option in patients with incurable disease. Continent diversion, such as the Indiana pouch, offers a long-term remedy to the appropriate patient, even one who has been irradiated, as reported by Mannel. Iatrogenic incontinence is distressing to the patient and her doctor. Webster and Kreder offer keen insight into the evaluation of patients who have postoperative, obstructive, voiding dysfunction. They describe an operative correction, the obturation shelf repair, quite similar to the paravaginal defect repair, which restores "normal anatomy" and results in excellent relief of voiding dysfunction in approximately 90% of their patients. Postoperative bladder care is of concern to the doctor, patient, and nursing staff. Noble's article on the timing of catheter removal is innovative and practical.

46,XY gonadal dysgenesis: three case reports demonstrating an evolution in management.

Treatment of phenotypic females with XY gonadal dysgenesis is evolving. In the past, these patients have routinely undergone hysterectomy with bilateral gonadectomy. Since the major concern in women with XY gonadal dysgenesis is ovarian malignancy, these patients need not only gonadectomy but frozen section and appropriate surgical staging based on histologic findings. However, even women with stage I dysgerminoma do not require hysterectomy. The state of the art in reproductive endocrinology makes it possible for us not only to offer them the development of secondary sexual characteristics with cyclic replacement therapy, but also the opportunity for childbearing with the use of embryo transfer.

A six-year experience with paravaginal defect repair for stress urinary incontinence.

One hundred forty-nine consecutive patients who had surgery from May 1890 through December 1986 were evaluated to assess the functional and anatomic results of the paravaginal defect repair for stress urinary incontinence. All patients had their preoperative assessment, operative procedure, and postoperative follow-up managed by the authors. Twelve percent of the patients had one or more previous surgical procedures for urinary incontinence. Sixteen percent of the patients had the preoperative diagnosis of urinary incontinence with mixed components of true stress incontinence and detrusor instability. Postoperatively, 6% of all patients developed evidence of cuff prolapse; 5% had an enterocele. In none of those patients did the defect prolapse to the hymen. Five percent of the patients had postoperative evidence of a persistent cystocele, all of which were smaller than they had been preoperatively. An assessment of the anatomic results of the repair demonstrates that meticulous attention must be paid to the proper repair of the paravesical defect, to support of the vaginal cuff, and to management of the cul-de-sac of Douglas to minimize postoperative anatomic defects. Ninety-seven percent of patients had excellent functional results with no postoperative complaints of stress urinary incontinence.

Testicular feminization syndrome: a case study of four generations.

This report deals with the complete form of testicular feminization in four generations of a single kindred. The four siblings who have had orchiectomy had no evidence of testicular malignancy. Because all four of the postpubertal patients have the complete form of the disorder, the prepubertal member is being managed expectantly, awaiting the onset of female secondary sexual characteristics at puberty. Other carriers may be identified as reproductive function continues.

Combined plastic and gynecological surgical procedures.

The purpose of the present study was to determine the extent to which the planned combination of one of several major plastic and gynecological surgical procedures may alter patient morbidity and postoperative hospitalization when compared with similar procedures carried out separately. A review of 10 consecutive years of operative procedures produced 63 patients who underwent combined gynecological and plastic surgical procedures. Thirty-three of the combined-surgery patients could be suitably matched with 2 control patients each to compare complications and length of hospital stay. The requirement for transfusion was significantly greater (p = 0.01) in the combined-surgery versus the paired-control groups. No other complications, however, were increased in the combined-surgery patients. There was a significant reduction (p = 0.005) in hospital stay of 1.92 postoperative days for two groups of combined-surgery patients versus the control groups. In all combined-surgery patients, patient response was favorable. Recommendations on preoperative planning and intraoperative and postoperative management are discussed. There is a perception in the surgical community that combining procedures unacceptably increases morbidity. For the past 12 years plastic and gynecological surgeons in our institution have offered combined procedures to our patients, with positive results and favorable patient response. A search of recent medical literature demonstrated several references to the planned combination of plastic and gynecological or general surgical procedures [2, 4, 5]. However, the only study with matched control patients dealt exclusively with abdominoplasty in association with one of five major gynecological procedures.

Adnexal torsion: a mind-twisting diagnosis.

We have reviewed cases of adnexal torsion surgically managed at Scott and White Clinic during the past seven years, and have found that a high index of suspicion is the clinician's best tool in diagnosing adnexal torsion.