Cystotomy Repair Research Articles

7897 Bladder Injury Caused by Uterine Manipulator

<h3>Study Objective</h3> This video demonstrates identification and management of a bladder injury caused by a uterine manipulator <h3>Design</h3> Surgical video <h3>Setting</h3> Academic medical center <h3>Patients or Participants</h3> A 34-year-old G0 with endometriosis, bilateral endometriomas, and subserosal fibroids desiring fertility underwent a robotic-assisted abdominal exploration with excision of endometriosis and myomectomy. Uterine manipulator was placed at the start of the case. Exposure to the surgical field was limited by inadequate uterine manipulation, which was thought to be attributed to the significant adhesive disease. At the start of the anterior compartment dissection, it was suspected that the uterine manipulator tip may have perforated into the bladder. A 3mm perforation was confirmed on cystoscopy. <h3>Interventions</h3> A bladder flap was further developed but the defect was too caudal to be accessed in this plane. The space of Retzius was entered and intentional cystotomy was made. The bladder injury was repaired transvesically with 2 sutures of 2-0 PDS. An additional suture was placed in the vagina to close the vaginal aspect of defect. The cystotomy was closed in a traditional 2-layer fashion. <h3>Measurements and Main Results</h3> Repeat cystoscopy confirmed a watertight closure of the bladder injury and the intentional cystotomy repair. The retropubic space was reperitonealized. The patient did well post-operatively with bladder decompression with foley catheter for 10 days. Subsequent CT cystogram showed no leakage of urine. The catheter was removed after the post-op imaging and a voiding trial. <h3>Conclusion</h3> This case highlights a rare complication of uterine manipulator use. There are benefits of using uterine manipulators especially in cases of advanced endometriosis and laparoscopic hysterectomy are well known and hence used readily in minimally invasive gynecologic surgery. It is therefore important to be aware of potential complications and have knowledge of how to address them.

A Comparative Study of Braided versus Barbed Suture for Cystotomy Repair.

BackgroundIn this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups.MethodsA retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.ResultsSixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005).ConclusionBarbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Robotic Cystotomy Repair and Ureteral Dissection Techniques

<h3>Study Objective</h3> The objective of this video is two-fold. First, to demonstrate the steps of cystotomy repair and highlight tips for post-operative management of cystotomies. Second, to review the anatomy and vascular supply of the ureter in order to describe safe ureteral dissection techniques. <h3>Design</h3> N/A. <h3>Setting</h3> The video presents clips of robotic-assisted cystotomy repair and ureteral dissection. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Understanding the steps of both repair and post-operative management of cystotomies is important for minimally invasive surgeons. Additionally, knowledge of the anatomy of the ureter in the pelvis can both aid in ureteral dissection and avoid ureteral damage at the common sites of injury.

The Use of Barbed Suture for Cystotomy Repair — a Novel Approach

Study Objective In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 poliglactin, poliglecaprone) versus barbed (V-Loc TM 90) suture. As a secondary outcome, we analyzed risk factors for suture preference between the two groups. Design Retrospective cohort study. Setting N/A Patients or Participants Surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Interventions Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgeon specialty, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p value < 0.05 was significant. Measurements and Main Results Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p= 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index was significantly higher in patients receiving a barbed suture repair (p=0.005). Conclusion Barbed suture is not inferior to standard braided suture for cystotomy repair and does not cause an increase in complication rate. Barbed suture offers a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI. In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 poliglactin, poliglecaprone) versus barbed (V-Loc TM 90) suture. As a secondary outcome, we analyzed risk factors for suture preference between the two groups. Retrospective cohort study. N/A Surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgeon specialty, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p value < 0.05 was significant. Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p= 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index was significantly higher in patients receiving a barbed suture repair (p=0.005). Barbed suture is not inferior to standard braided suture for cystotomy repair and does not cause an increase in complication rate. Barbed suture offers a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Sock Laparoscopy: Very Low-Fidelity Simulation to Develop Advanced Skills

Study Objective Demonstrate the construction and use of very low-fidelity simulation to practice advanced laparoscopic skills in gynecologic surgery. Design Educational demonstration using affordable materials and a basic laparoscopic box trainer. Setting N/A Patients or Participants N/A Interventions N/A Measurements and Main Results N/A Conclusion Laparoscopic surgical training is an important aspect of OB/GYN residency and successful completion of the Fundamentals of Laparoscopic Surgery is now required. A laparoscopic box trainer provides a platform for practicing basic and advanced laparoscopic skills. Very low-fidelity models can be quickly created using inexpensive material to simulate more advanced skills such as vaginal cuff closure, cystotomy repair, myomectomy closure with baseball stitch of the serosa, bowel serosa repair, ovarian cystectomy, and peritoneal biopsy.

A Strategic Approach to a Total Laparoscopic Hysterectomy for an Advanced Cesarean Section Scar Ectopic Pregnancy with Cystotomy Repair.

Study Objective Present an interesting case of an advanced cesarean scar ectopic pregnancy that failed medical management and underwent treatment with a total laparoscopic hysterectomy. Design Video Case Report. Setting Tertiary Referral Hospital at a community-based OB/GYN residency program. Patients or Participants 37-year-old G3P3013 at 9 weeks gestation with a cesarean scar ectopic pregnancy. Interventions This video will present an interesting case of a 37yo G5P3013 that presented with a 9-week cesarean scar ectopic pregnancy. Initial treatment was with injection of KCL into the fetal heart and methotrexate into the gestational sac at 10 weeks gestation. The patient presented 5 weeks after initial treatment with persistent pain and vaginal bleeding. The patient was the thoroughly counseled on her treatment options. She had no desire for future pregnancy and the plan was made for total laparoscopic hysterectomy with bilateral salpingectomy. This video presentation shows how as strategic anatomic approach using isolation of the blood supply and utilizing avascular spaces can allow this case to be completed in a minimally invasive fashion. This case will also present the steps to repairing an incidental cystotomy that was encountered in the dissection Measurements and Main Results N/A Conclusion Advanced cesarean scar ectopic pregnancy can be treated in a minimally invasive fashion with total laparoscopic hysterectomy when future fertility is not desired.

Incidence of and Risk Factors for Postoperative Urinary Tract Infection After Abdominal and Vaginal Colpopexy.

The aims of the study were to determine the rate of urinary tract infection (UTI) in women undergoing colpopexy and to evaluate risk factors and timing for postoperative UTI. This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2017. Patients were grouped into those with and without UTI. Pairwise analysis between groups was performed using χ2 and Fisher exact test. Multivariable logistic regression was used to identify independent predictors of UTI. Of 23,097 women who underwent colpopexy, 1079 (4.7%) experienced a postoperative UTI. Urinary tract infection was most frequently diagnosed in the second week after surgery (38.2%), compared with week 1 (19.9%), 3 (22.8%), and 4 (19.1%) (P < 0.001). Patients diagnosed with a UTI were more likely to have insulin-dependent diabetes (2.8% vs 1.7%, P = 0.006), coagulopathy (1.3% vs 0.7%, P = 0.04), and chronic steroid use (2.7% vs 1.8%, P = 0.004). Patients with a UTI versus those without a UTI were more likely to have undergone an intraperitoneal or extraperitoneal vaginal colpopexy (37.8% vs 30.5%, P < 0.001) and (29.8% vs 25.6%, P = 0.003), respectively, and more likely to undergo combined anterior and posterior colporrhaphy (17.1% vs 12.2%, P < 0.001). After logistic regression, intraoperative cystotomy repair (adjusted odds ratio = 2.93, 95% confidence interval = 1.54-5.59) was the most significant risk factor. Postoperative UTI after colpopexy occurred less frequently than previously reported. Vaginal colpopexy is associated with a higher risk of UTI than abdominal or laparoscopic colpopexy.

Partial Cystectomy for Deeply Infiltrating Endometriosis of the Bladder with Cystotomy Repair

Video Objective To demonstrate safe surgical technique and management of partial bladder cystectomy and simple cystotomy repair due to deeply infiltrating endometriosis (DIE) using the Xi DaVinci robot. Setting A 32yo patient with dysmenorrhea and dyspareunia found to have DIE of the bladder undergoing surgical management at a large academic center. Interventions The bladder lesion was initially found on preoperative MRI and confirmed during robotic assisted surgery. The lesion was felt to be full thickness and required partial bladder cystectomy for adequate excision of the implant. The DaVinci robot was used to remove the lesion with good margins. The resulting cystotomy repair was repaired, with good seal noted when the bladder was backfilled and on cystoscopy. A foley catheter was maintained for 7 days postoperatively and removed after a cystogram showing adequate bladder recovery. Conclusion Deeply infiltrating endometriosis of the bladder is rare but can be safely managed with laparoscopic partial bladder cystectomy and cystotomy repair. Adequate preoperative planning and thorough inspection of the lesion during surgery can assist with full removal of the lesion, which improves patient symptoms and decreases incidence of recurrence.

2366 Laparoscopic Repair of Intraoperative Cystotomy

Video Objective The purpose of this video is to demonstrate the technique for laparoscopic repair of an intraoperative cystotomy, at the time of total laparoscopic hysterectomy. Setting In the particular case presented in this video, a large paracervical fibroid distorts the anatomy of the lower uterine segment. While developing the bladder flap, an inadvertent cystotomy 4 centimeters in diameter is created, immediately identified, and subsequently repaired laparoscopically by standard surgical guidelines. The risk of a urinary tract injury during laparoscopic hysterectomy ranges from 0.735-1.8%; the risk of a bladder injury is three times more likely than that of a ureteral injury. A number of patient characteristics increase the risk of an injury, including endometriosis, a history of cesarean sections, and large fibroids that distort uterine anatomy. Urinary tract injuries that go unrecognized at the time of surgery are associated with increased postoperative morbidities, specifically hospital readmission, sepsis, and fistula formation. Interventions The cystotomy repair is demonstrated in standard fashion after completion of the hysterectomy and confirming the injury does not involve the trigone. Bladder dome injuries greater than 1 centimeter require primary repair, which should be completed in 2 layers with delayed absorbable suture. The first layer opposes the edges of the bladder mucosa and muscularis and the second layer closes the bladder serosa. Following repair, the bladder is retro filled with normal saline to ensure a watertight closure. Imbricating sutures can be utilized on the serosa to enhance closure as necessary. A cystoscopy confirms intact repair and bilateral ureteral efflux. An indwelling foley catheter is maintained for 1-2 weeks postoperatively. Conclusion Recognition and repair of a bladder injury at the time of original surgery optimizes patient outcomes. A two layer closure using excellent tissue reapproximation is essential for ideal wound healing.

32: Incidence and risk factors of early post-operative small bowel obstruction in patients undergoing hysterectomy for benign indications

The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO), occurring within the first month of surgery, after benign hysterectomy. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Patient demographics, clinical and surgical factors were obtained. Patients were then stratified into those with and without and SBO. Differences between groups were evaluated using Chi-squared and Fisher’s exact tests for categorical variables, and the Student’s t-test for continuous variables. Multivariable logistic regression was used to identify significant independent predictors of SBO. There were 286 (0.06%) occurrences of SBO out of 47,937 hysterectomies. Patients experiencing SBO were more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, p<0.001), LOA (5.2% vs 2.1%, p<0.001), appendectomy (1.7% vs 0.5%, p=0.02), and cystotomy repair (1.0% vs 0.3%, p= 0.002). After logistic regression, mode of hysterectomy was not a significant predictor of SBO, while contaminated and infected wounds (aOR=5.93, 95% CI: 2.71-12.96) and perioperative transfusion (aOR=5.21, 95% CI: 3.66-7.29) were the most significant risk factors. Additional risk factors for early SBO included non-white race (aOR= 1.83, 95% CI: 1.34-2.48), older age (aOR=1.03, 95% CI: 1.02-1.05), prior abdominal or pelvic surgery (aOR=1.45, 95% CI: 1.26-2.60), operating times exceeding 170 minutes (aOR=1.90, 95% CI: 1.39-2.59), uterine weight greater than 250 grams (aOR=1.54, 95% CI: 1.11-2.14), lysis of adhesions (aOR=2.12, 95% CI: 1.24-3.66), and concurrent appendectomy (aOR=2.98, 95% CI: 1.20-7.41). Early small bowel obstruction is a rare complication of benign hysterectomy and is unrelated to route of hysterectomy after adjusting for confounders. Multiple risk factors related to abdomino-pelvic adhesive disease were associated with a higher risk of bowel obstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications

Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P<.001) and were more likely to smoke (21.0% vs 15.8%, P= .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P= .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P= .02), and cystotomy repair (1.0% vs 0.3%, P= .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

Teaching Cystotomy Repair: Low Fidelity Model Provides Effective Simulation at Minimal Cost

PURPOSE: To develop an inexpensive bladder model that can be used to teach Ob-Gyn Residents open and laparoscopic cystotomy repair. BACKGROUND: Recognition of cystotomy and repair is a requirement of Ob-Gyn surgical milestones. Simulation products currently exist for cystoscopy but not for cystotomy repair. METHODS: Pilot study of a novel low fidelity bladder model that can be used for simulation of both open and laparoscopic cystotomy repair. A cystotomy model was created using the following materials: small whoopee cushion “bladder mucosa”, shelf liner “bladder muscularis” and Press'n Seal® for “serosa.” Markings were placed inside the cushion to represent the trigone with ureteral orifices. Residents were asked to identify the model’s anatomic landmarks and rate their confidence in identifying cystotomy and performing both and open and laparoscopic cystotomy repair, pre- and post-simulation. RESULTS: 16 bladder models were constructed for approximately $1.50 per model. The model is reusable and manipulated well with surgical instruments and suture both open and laparoscopically; the model was a bit large for the laparoscopic trainer and lighting became a challenge for suturing. All participating residents correctly identified the anatomic structures post-simulation compared to 12/13 pre-simulation. Change in mean resident confidence was statistically significant for identifying cystotomy (pre M=3.1/5 vs. post M=4.2/5, P=.009) and performing open cystotomy repair (pre M=2.4/5 vs. post M=4/5, P=.03) but not for laparoscopic repair (pre M=1.6/5 vs. post M 3.1/5, P=.09). DISCUSSION: Our bladder model is easily constructed and inexpensive. It performs well for open cystotomy repair but has been decreased in size to better perform laparoscopically.

282 - Robotic Cystotomy for Pessary Extraction with Vesicovaginal Fistula Repair

This video case presentation discusses the step-by-step robotic surgical approach to the removal of a pessary, via cystotomy, followed by vesicovaginal fistula and cystotomy repair. The case involves a 77-year-old woman who had a Gellhorn pessary placed 12 years prior, without further evaluation or removal, presenting with vaginal leakage of urine. Imaging, followed by cystoscopy, confirmed the pessary within the urinary bladder. A robotic approach to the foreign body extraction was then performed. A cystotomy was made for pessary removal. The vesicovaginal fistula was evaluated and closed in two layers, followed by a bladder closure in two layers. A pelvic drain was then inserted. The patient denied leakage of urine at her postoperative appointment. This robotic surgical approach demonstrates ease of dissection, a method for thorough anatomy surveillance, and a method for successful repairs in complicated urogynecologic cases.

Single layer cystotomy closure of excised porcine bladders with barbed versus smooth suture material.

To determine which of 2 suture materials would be superior in terms of closure time and leakage pressure in open single-layer cystotomy closure. Experimental study. Twenty-four freshly harvested porcine urinary bladders. A cystotomy was performed and the incision closed with a single layer simple continuous suture pattern with barbed (n = 12) or smooth (n = 12) suture. Time required for closure was measured. Each bladder was connected to a system for monitoring intraluminal pressure while inflated with saline until leakage occurred. Intraluminal pressure at time of initial leakage and leakage site were recorded. Two-sample t tests were used to compare maximum leakage pressure and closure time between the 2 groups. P < .05 was considered significant. All bladders were sutured successfully with no difference in mean closure time (barbed suture 296 ± 46 seconds; smooth suture 293 ± 26 seconds) (P = .821). There was no difference in mean leakage pressure of porcine urinary bladder incisions closed in a single layer with barbed suture (28.8 ± 10.4 mm Hg) compared with smooth suture (30.6 ± 8.8 mm Hg) (P = .642). Barbed suture provides comparable cystotomy repair to smooth suture, and no benefit to its use was identified in an open procedure. Barbed suture closure should be evaluated for adequate tensile strength in the presence of urine, satisfactory in vivo healing of cystotomies, and lack of long-term urolith formation in dogs and cats.

Robotic Cystotomy for Pessary Extraction With Vesicovaginal Fistula Repair

Study ObjectiveTo demonstrate a robotic approach to foreign body extraction and vesicovaginal fistula repair. DesignVideo case presentation with narration discussing the step-by-step robotic surgical approach to the removal of a pessary, via cystotomy, followed by vesicovaginal fistula and cystotomy repair. SettingUniversity of Louisville Hospital. The local Institutional Review Board deemed the video exempt from formal approval (Canadian Task Force Classification III). PatientA 77-year-old woman presented with complaints of vaginal leakage of urine, dysuria, and pelvic pain. She had a Gellhorn pessary placed 12 years prior without further evaluation or removal. The patient had a leukocytosis with a pseudomonal urinary tract infection. Imaging confirmed a Gellhorn pessary free floating within the urinary bladder. InterventionsThe patient was taken to the operating room for an exam under anesthesia where a copious amount of urine was found coming from the vagina. A small vesicovaginal fistula was appreciated but could not be thoroughly explored. Cystoscopy revealed the foreign object in the urinary bladder. A robotic approach to the foreign body extraction was then performed with the davinci Xi robot (da Vinci Xi Intuitive Surgical, Sunnyvale, CA). The pessary was evident in the bladder on abdominal entry. Cystotomy was performed with the monopolar curved scissors. A vaginal EEA sizer was found to be advanced through the vesicovaginal fistula. The pessary was then grasped and removed from the bladder. Bilateral ureteral orifices were visualized. The fistula was then closed in 2 layers with 3-0 vicryl V-loc sutures (Covidien Medtronic, St. Paul, MN). The bladder was then closed in 2 layers with 3-0 vicryl V-loc sutures. A no. 15 Jackson-Pratt drain was then inserted through the right lower quadrant port and placed in the pelvis under direct visualization. The pessary was then removed via mini-laparotomy. A Foley catheter was left in place for prolonged drainage for a total of 6 weeks because of the multiple bladder repairs on the inflamed tissue. The patient denied any leakage of urine at her following postoperative appointment. ConclusionA robotic surgical approach, as an alternative to vaginal surgery, improves ease of dissection, provides a method for thorough anatomy surveillance, and can be used for successful repairs in complicated urogynecologic cases.

Do Faculty and Residents Agree on Obstetrics and Gynecology Surgical Training Needs?

BACKGROUND: Surgical education is an essential, complex, component of residency training. Resident and faculty needs are important in guiding the educational agenda; studies demonstrate that these groups do not always agree on needs. METHODS: A 50-item needs assessment tool was administered during scheduled meetings at our single academic center to capture resident and faculty perceptions of the adequacy of our program's surgical training; all items were ranked on a 5-point agreement scale. Content domains included feedback, surgical preparation, intra-operative performance, simulation, and the Ob-Gyn Milestones procedures (we assessed satisfaction with training and the perceived helpfulness of simulation to improve performance of those procedures). RESULTS: Twelve surgical faculty (80%) and 13 residents (87%) completed the needs assessment; t tests compared resident/faculty group differences. Both groups agreed on the adequacy of surgical content domains, however, faculty consistently self-reported delivering feedback at a significantly higher level than residents' perceived receiving it (P&lt;.05). Both groups were least satisfied with training in cystotomy repair, breech vaginal delivery, and 3rd/4th-degree laceration repair. Both rated simulation in breech vaginal delivery and vaginal hysterectomy as most useful for improving performance. For all procedures, faculty consistently rated at significantly higher levels, simulation's usefulness to improve procedure performance. DISCUSSION: Although residents and faculty agree on areas needing most improvement, differences exist in perception of feedback and usefulness of simulation to improve performance.

Utility of Postoperative Voiding Cystourethrogram After Lower Urinary Tract Repair.

To characterize indications, timing, and results of voiding cystourethrogram (VCUG) studies after repair of the lower urinary tract and to determine how these results impact clinical management. Women who underwent a VCUG between January 2006 and December 2012 were identified from a radiology billing database. After excluding women with abdominopelvic malignancies, demographic, clinical, index procedure and lower urinary tract repair characteristics, and VCUG results were analyzed. The impact of abnormal VCUG results on clinical management was assessed. Data were analyzed from 245 VCUG studies performed a median of 10 days (interquartile range, 8-12 days) after lower urinary tract repair. When classified by procedure type, VCUGs were performed a median of 9 days (7-13 days) after cystotomy repair, 11 days (10-12 days) after vesicovaginal fistula closure and 10 days (7-11 days) after diverticulectomy. Abnormal findings were noted in 7 of 245 (2.9%) VCUGs and included contrast extravasation (5/7) and urinary retention (2/7). In all cases, the abnormal VCUG prompted a change in clinical management with extended use of an indwelling catheter or intermittent self-catheterization in 1 case of urinary retention. Voiding cystourethrograms are a useful clinical tool in guiding the duration of Foley catheter use after lower urinary tract repair. Depending on clinical practice, VCUGs may reduce catheter-associated morbidity by facilitating earlier catheter removal and, in the minority of cases, may identify patients with incomplete postoperative healing.

Simulation of Cystotomy Repair Utilizing Fresh-Frozen Porcine Bladder

Abstract Objective: To evaluate the porcine bladder for simulation of cystotomy repair and assess the educational benefit of didactics and demonstration on the technical skill of cystotomy repair. Materials and Methods: The model was a large porcine bladder. The subjects were residents. This was a prospective design using questionnaires and OSATS. An initial lab with evaluation was followed by didactics and a demonstration, followed by another lab with repeat evaluation. Results: The fidelity of the model was uniformly rated as good for repair of a dome injury but not for a trigone injury. Following the didactics and demonstration there was significant improvement in technique and overall pass rate as measured by OSATS. Following the labs there was substantial improvement in self-assessment of comfort with repair of a bladder-dome injury. Conclusions: The large porcine bladder is an appropriate model for simulation of repair of a cystotomy in the dome of the bladder. (GYNECOL SURG 30:141)

Histology surrounding cystotomy healing in a Sprague–Dawley rat model

The purpose of this study was to histologically chronicle wound healing following cystotomy repair using a small animal model. Thirty female Sprague-Dawley rats were included in this study. Twenty-eight rats underwent a vertical cystotomy in the bladder dome, which was repaired in a single continuous fashion. Two rats served as histological controls. Following cystotomy repair, groups of three to four rats were studied at single day intervals for 4 days, then at 2-day intervals until 10 days post-repair. The animal bladders were harvested and examined for inflammation, scar formation, and bladder healing. Thirty rat bladders were histologically examined. An inflammatory wound phase was observed during the first 4 days after wounding. Transition from acute to chronic inflammation was observed at day 2 with chronic inflammation persisting through day 10. Inflammation severity peaked 4 days post-wounding without regression through day 10. Evidence of proliferative phase wound healing was first observed 4 days post-wounding. Early increases in wound healing are due to inflammatory events such as fibrin plugging of the wound. Later developments after day 4 are due to wound proliferation, collagen deposition, and re-epithelialization. Additionally, wound healing in the rat bladder is observed on a continuum and not necessarily in discrete stages observed on precisely the same postoperative day in each animal.

Failed Omental Flap Vesicovaginal Fistula Repair Subsequently Repaired Laparoscopically Without an Omental Flap

Conventional wisdom suggests that vascular interposition flaps are helpful in the treatment of all patients with vesicovaginal fistulas. Complicated fistulas are often treated with interposition omental flaps; however, failed omental flap repairs have not been described without the use of another interposition flap. A 52-year-old woman with a history of cystotomy repair at the time of hysterectomy and a subsequent abdominal omental flap vesicovaginal fistula repair failure underwent a successful repair using a laparoscopic-layered closure of her fistula without omental flap. A failed omental flap vesicovaginal fistula repair can be repaired laparoscopically and without an omental flap.