Complications Of Gynecologic Procedures Research Articles

Repair of complex vesicovaginal fistulas by combining a rotational bladder flap and full thick vascular peritoneal interposition.

To present the experience of repairing iatrogenic vesicovaginal fistulas (VVFs) using a rotational bladder flap and peritoneal interposition technique. Between January 2009 and June 2014, a total of 18 patients (mean age, 44.0 years; age range, 29-51 years) with VVFs were treated using a transperitoneal approach. All VVFs were complications of gynecologic procedures. Twelve patients experienced recurrent VVFs and one patient had a concomitant rectovaginal fistula after radiotherapy. The fistula was approached transabdominally. The peritoneum covering the bladder was isolated to expose the bladder and prepare for the interposition. The bladder was opened along the sagittal plane to the fistula and a bladder flap was rotated downward to fill the fistula defect. The vaginal defect was closed, then a flap using the isolated peritoneum was interposed and fixed between the vagina and bladder. A ureteral re-implantation was performed in one patient. All VVF procedures were performed by one urologist (SW). Repair of the rectovaginal fistula was performed by a general surgeon at the same time. Seventeen patients (success rate = 94% [100% for primary cases and 92% for recurrent cases]) had no evidence of recurrent VVF at a mean follow-up of 20 months (range, 6-36 months). The only patient who had previously undergone a repair procedure failed. A transperitoneal approach with the use of a rotational bladder flap and peritoneal interposition might be a feasible and reliable procedure for surgical management of iatrogenic VVFs, especially in complicated cases. Neurourol. Urodynam. 35:934-938, 2016. © 2015 Wiley Periodicals, Inc.

Omental Prolapse Through Vaginal Cuff Dehiscence

A 31-year old female with a history of laparoscopic assisted vaginal hysterectomy presented by ambulance to the emergency department with acute onset of abdominal pain and a vaginal protrusion which occurred while straining to pass a bowel movement.  Physical examination was notable for a flat but slightly tender abdomen, normal bowel sounds, scant vaginal bleeding, and a 15cm long, blood-tinged mass protruding from the vagina.  A brief and unsuccessful attempt at reduction was made by the emergency physician.  Obstetrics and Gynecology was consulted, and the patient was taken to the operating DIAGNOSIS Omental prolapse through vaginal cuff dehiscence.  Following vaginal hysterectomy, the vaginal cuff is closed surgically1.  Occasionally, this site can dehisce, allowing abdominal contents to enter the vagina or protrude through the vaginal canal. Vaginal cuff dehiscence is estimated to have a rate of 0.39%. It is more commonly seen after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy, (0.28%)2.Risk factors include trauma from sexual intercourse, repetitive Valsalva maneuvers, smoking, malnutrition, anemia, diabetes, immunosuppression, and corticosteroid use2.  Cases typically present as vaginal spotting or post-coital bleeding, and occasionally pelvic pressure or protrusion2.  Most cases occur within weeks to months after the procedure, but some can present years later. Patients are at risk for infection due to exposure of peritoneal contents to vaginal and skin flora.  Management includes administration of broad-spectrum antibiotics.  Partial dehiscence can be managed with rest, but large dehiscence is usually managed surgically.This case highlights the importance of the pelvic exam in patients with vaginal bleeding and abdominal pain, and care should be taken to not mistake protruding omental tissue for prolapsed vaginal mucosa.  REFERENCES 1.     Binz NM, et al. Complications of Gynecologic Procedures. Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.2.     Clarke-Pearson D, & Geller E. Complications of Hysterectomy. Obstetrics & Gynecology, 121 (3), 654-673; 2013.

Advances in Gynecologic Imaging and Intervention

Advances in diagnostic imaging of the female genital tract facilitate characterization of many pelvic masses. Preoperative assessment of gynecologic malignant tumors provides information that may alter the surgical approach or timing of radiation therapy. Image-guided biopsy accurately confirms recurrent malignant lesions. Transcervical techniques have improved diagnostic assessment of infertile couples; thus, effective and inexpensive treatment options can be offered. Postoperative complications of gynecologic procedures can be detected with imaging, and many can be treated with image-guided techniques.