Transvaginal Approach Research Articles

The volume of the cerebellum in the second semester of gestation.

Background and aimsThe cerebellum (“little brain”), the largest part of hind brain, lies in the posterior cranial fossa, beneath the occipital lobe and dorsal to the brainstem. It develops over a long period: it is one of the first structures in the brain to begin to differentiate, but one of the last to mature. The use of ultrasonography has significantly improved the evaluation of fetal growth and development and has permitted prenatal diagnosis of a variety of congenital malformations.The aim of our study was to evaluate the cerebellar growth and development using 2 different measuring techniques: microMRI and ultrasound technique. The cerebellum measurements were related to gestational age.MethodsWe used 14 human fetuses corresponding to 15–28 gestational weeks, immersed in a 9% formalin solution. Magnetic Resonance Imaging (MRI) was performed by employing a Bruker BioSpec 70/16USR scanner (Bruker BioSpin MRI GmbH, Ettlingen, Germany), operated at 7.04 Tesla for cerebellar volume measurement. Ultrasonographic measurements of the cerebellum diameter were performed on 14 pregnant women, 15 – 28 gestational weeks. Ultrasound scan used 5–10 MHZ for transvaginal approach. Taking into consideration the values of the cerebellum dimensions and considering the general shape of the cerebellum as a transverse ellipsoid, the volume of the cerebellum was calculated by a mathematical formula for ellipsoid volume.ResultsThe study correlates the measurements from the microMRI study with the ultrasounds data and the results are superposable. Both established the exponential volume growth after the 22–23 GW. We used the ellipsoid volume formula for the cerebellar volume using the half of the three diameters of the cerebellum determined by ultrasound measurements:Cerebellar Volume = Ellipsoid volume = 3/4 π r1 r2 r3ConclusionThere is a linear correlation between the microMRI measurements and ultrasound determinations. Based on all collected data we could apply an easy formula to calculate the volume of cerebellum, a useful criterion in the evaluation of the cerebellar development and the appreciation of the gestational age.

Prolapse of the apical compartment. Surgical techniques that preserve the uterus. The benefits of the Saba Nahedd technique

The prolapse of the apical compartment is defined as the herniation of the vaginal apex below the plane of the hymen and it is most often associated with an anterior and/or posterior vaginal wall prolapse. The vaginal apex is formed by the uterus or cervix and/or the vaginal cuff in women who received a subtotal or total hysterectomy respectively. The etiology of the apical prolapse is connected to the integrity of the connective tissue which is contained in the uterosacral, cardinal ligaments and the endopelvic fascia. The changes in the life style and beliefs, the current tendency towards a less invasive surgery which involves reduced surgical risk and lower costs have determined more women with genital prolapse to opt for surgical methods that preserve the uterus. These methods include abdominal, vaginal or laparoscopic routes, the chose depending on the local situation and the experience of the surgeon. One of the vaginal techniques which have showed very good results in terms of postoperative morbidity, rate of recurrence and life quality is the “Saba Nahedd” procedure which uses a special kit consisting of an isthmic and a suburethral strip and special clamps for the suspension of the uterus. The aim of this paper is to present the current data on the surgical options that preserve the uterus in women with uterine prolapse, especially, grade II and III with focus on the transvaginal approach using the S.N. method compared with other transvaginal techniques that preserve the uterus.

The NOVEL trial: natural orifice versus laparoscopic cholecystectomy-a prospective, randomized evaluation.

The evolution of Natural Orifice Translumenal Endoscopic Surgery® (NOTES®) represents a case study in surgical procedural evolution. Beginning in 2004 with preclinical feasibility studies, and followed by the creation of the NOSCAR® collaboration between The Society of American Gastrointestinal and Endoscopic Surgeons and the American Society for Gastrointestinal Endoscopy, procedural development followed a stepwise incremental pathway. The work of this consortium has included white paper analyses, obtaining outside independent funding for basic science and procedural development, and, ultimately, the initiation of a prospective randomized clinical trial comparing NOTES® cholecystectomy as an alternative procedure to laparoscopic cholecystectomy. Ninety patients were randomized into a randomized clinical trial with the primary objective of demonstrating non-inferiority of the transvaginal and transgastric arms to the laparoscopic arm. In the original trial design, there were both transgastric and transvaginal groups to be compared to the laparoscopic control group. However, after enrollment and randomization of 6 laparoscopic controls and 4 transgastric cases into the transgastric group, this arm was ultimately deemed not practical due to lagging enrollment, and the arm was closed. Three transgastric via the transgastric approach were performed in total with 9 laparoscopic control cases enrolled through the TG arm. Overall a total of 41 transvaginal and their 39 laparoscopic cholecystectomy controls were randomized into the study with 37 transvaginal and 33 laparoscopic cholecystectomies being ultimately performed. Overall total operating time was statistically longer in the NOTES® group: 96.9 (64.97) minutes versus 52.1 (19.91) minutes. There were no major adverse events such as common bile duct injury or return to the operating room for hemorrhage. Intraoperative blood loss, length of stay, and total medication given in the PACU were not statistically different. There were no conversions in the NOTES® group to a laparoscopic or open procedure, nor were there any injuries, bile leaks, hemorrhagic complications, wound infections, or wound dehiscence in either group. There were no readmissions. Visual Analogue Scale (VAS) pain scores were 3.4 (CI 2.82) in the laparoscopic group and 2.9 (CI 1.96) in the transvaginal group (p = 0.41). The clinical assessment on cosmesis scores was not statistically different when recorded by clinical observers for most characteristics measured when the transvaginal group was compared to the laparoscopic group. Taken as a whole, the results slightly favor the transvaginal group. SF-12 scores were not statistically different at all postoperative time points except for the SF-12 mental component which was superior in the transvaginal group at all time points (p < 0.05). The safety profile for transvaginal cholecystectomy demonstrates that this approach is safe and produces at least non-inferior clinical results with superior cosmesis, with a transient reduction in discomfort. The transvaginal approach to cholecystectomy should no longer be considered experimental. As a model for intersociety collaboration, the study demonstrated the ultimate feasibility and success of partnership as a model for basic research, procedural development, fundraising, and clinical trial execution for novel interventional concepts, regardless of physician board certification.

Transvaginal natural orifice transluminal endoscopic surgery in female urologic diseases

Objective To describe our experience with the transvaginal natural orifice transluminal endoscopic surgery (NOTES) in female patients, and to evaluate its clinical value. Methods Between May 2010 and April 2017, a total of 289 female patients underwent transvaginal NOTES in our center, including 31cases of adrenal tumors, 46 cases of renal tumors, 188 cases of non-functional kidneys, 5 cases of renal cysts, 4 cases of duplex kidney, 7 cases of renal tuberculosis and 8 cases of renal pelvis tumors. Among them, 146 cases were on the left side, 142 cases on the right side, and 1 case on both sides (renal cysts). The median age was 39.4 (range 23 to 76) years, and the median body mass index was 21.8(range 15.4 to 32.6)kg/m2. After general anesthesia, the patients were positioned in lithotomy with ipsilateral lumbar at 30°-60° angle to the floor. Hybrid and pure transvaginal NOTES were performed. The specimen was removed through an extended incision at the posterior vaginal fornix. Results Transvaginal NOTES was successfully completed in 281 patients. Two patients required conversion to suprapubic-assisted laparoendoscopic single-site surgery because of the rectal injury in pure transvaginal NOTES nephrectomy. Six patients underwent open conversion. The various transvaginal hybrid NOTES procedures included adrenalectomy (31 cases), nephrectomy (206 cases; simple 174 cases, radical 32 cases), partial nephrectomy (13 cases), heminephroureterctomy for duplex kidney (4 cases) and hybrid endoscopy for nephroureterectomy (7 cases). The mean operative time was 105 min (45-310 min), the mean estimated blood loss was 87 ml (20-800 ml), the mean visual analogue score (VAS) of 48 hours after operation was 2.5 (1-4) points and the mean hospitalization was 7.3 d (4-13 d) for transvaginal hybrid NOTES. The various pure transvaginal NOTES procedures included nephrectomy (22 cases; simple 21, radical 1), renal cyst excision (5 cases). The mean operative time was 170 min (60-320 min), the mean estimated blood loss was 140 ml (20-500 ml), the mean VAS of 48 hours after operation was 1.7 (1-3) points and the mean hospitalization was 5.5 d (3-10 d) for transvaginal pure NOTES. Complications occurred in 56 cases (19.38%), including 20 cases (6.92%) of severe complications, and no death occurred. After a mean follow-up of 51 (range 3 to 86) months, umbilicus scar was hidden. The incision in the vagina healed well. No infection in the abdominal or pelvic cavity or celiocele occurred. The umbilicus scar is not obvious after surgery, and 3 months after surgery.The median Patient Scar Assessment Questionnaire (PSAQ) score was 38 (31-58) and the median Female Sexual Function Index (FSFI) score was 28.2 (22.5-32.2), and the quality of life index was significantly higher than that of preoperation. Conclusions Transvaginal NOTES could treat variousprimary diseases, and improve the postoperative quality of life. It does not increase the incidence of related complications, or cause negative effect on the female sexual function, pregnancy or fertility. It can lead to good cosmetic outcome and less pain, which is worth applying in clinical practice. Key words: Natural orifice transluminal endoscopic surgery (NOTES); Transvaginal approach; Female; Urologic diseases

Transvaginal Resection of an Infected Sacrocolpopexy Mesh by Single-Port Trocar

Study ObjectiveLaparoscopy using a single port improves morbidity while keeping the same level of requirement. This technique has been evaluated in gynecology for salpingectomy, ovarian surgery, and hysterectomy. Here, the authors illustrate a new use of a single port using the transvaginal approach. DesignCase report (Canadian Task Force classification III). SettingTertiary referral center in Strasbourg, France. PatientWoman age 59 years. InterventionSingle-port platform used in the transvaginal approach for resection of sacrocolpopexy mesh. The local institutional review board approved the video. Measurements and Main ResultsA 59-year-old woman suffering from insulin-dependent diabetes and a tobacco user had 2 laparoscopic sacrocolpopexies for recurrent rectocele, the first in 2007 and the second in 2012. The sequences were marked by mesh erosion and granuloma in the vagina, requiring its surgical excision in 2016. The patient was then symptomatic, with an increasingly foul-smelling vaginal discharge with recurrent mesh erosion. Magnetic resonance imaging showed an abscess formation along the length of the mesh to the promontory. The patient then underwent surgery, realized under probabilistic antibiotic therapy, consisting of complete excision of the sacrocolpopexy mesh by the transvaginal approach. After putting the single-port trocar (GelPoint; Applied Medical, Rancho Santa Margarita, CA) into the vagina and obtaining distension with the insufflator (AirSeal; Conmed, Utica, NY), classic laparoscopic instruments were introduced by the single-port trocar. The mesh was entirely resected in the retroperitoneal space. Mesh was again used because the exposed space is almost always surrounded by loose granulation tissue that facilitates dissection and also prevents injury to adjacent structures such as bladder, rectum, and peritoneum. Moreover, the opening of adjacent structures will manifest gas leaks and, consequently, loss of the pneumovagina. At the end of procedure, the vagina is not closed to permit optimal drainage with a multitubular drain in the dissection space. The surgery lasted 60 minutes. The mesh excision was completed with relative ease, and there was no blood loss. Bacteriologic examination revealed the presence of Streptococcus anginosus, Klebsiella pneumoniae, and Bacteroides fragili. The operating suites were simple with great cicatrization after 6 weeks. The principal difficulties of this surgery were obtaining a good seal by the creation of cutaneous sutures. Finally, there are less conflicts between the instruments inside the single-port trocar used in transvaginally because of a more limited dissection space. Indeed, the rate of mesh erosion reached 2.4% and, in case of infection, justifies this excision. ConclusionThe transvaginal use of a single-port trocar represents a good alternative, allowing easy resection of the sacrocolpopexy mesh while remaining in the retroperitoneal space.

Measuring leading placental edge to internal cervical os: Transabdominal versus transvaginal approach.

Transabdominal and TV measurements of the leading placental edge to the internal cervical os were performed on 369 consecutive pregnancies of 16-41 weeks' gestation. The difference (TA-TV) from the mean was calculated and plotted against gestational age. Bland-Altman plots and paired t-tests were used to look at the differences in TA/TV measurement. Screening performance of a transabdominal approach was compared to a transvaginal 'gold standard'. Nonparametric methods were used to calculate the area under the receiver operator characteristics (ROC) curve. Intra-/interobserver variations were also calculated. Of the pregnancies, 278 had a leading placental edge that was visible with the TV approach. Differences (TA-TV) ranged from -50 mm to +57 mm. Bland-Altman plot shows that TA measurements overestimated the distance compared with the TV measurements; the average difference in measurement was 12.0 mm (95% confidence interval 9.9-14.1). The sensitivity, specificity and negative predictive values of a TA approach were 18.2%, 97.5% and 87.2%, respectively. The receiver operator characteristics area between gestational weeks 16-23 was 0.81 (95% CI: 0.76-0.86). The TA approach has a low sensitivity for detecting a low-lying placenta as choosing a TA cut-off with sensitivity >90% will decrease the specificity to 50%.

The Effect of Preoperative Phenazopyridine on Urinary Retention Following Midurethral Sling.

The aim of this study was to determine the effect of preoperative oral phenazopyridine on short-term voiding dysfunction in patients undergoing a retropubic midurethral sling. We conducted a retrospective cohort study in subjects undergoing a retropubic midurethral sling comparing those who received preoperative oral phenazopyridine with those who did not. We included all women who underwent a retropubic midurethral sling without concomitant procedures under general anesthesia at our institution. Slings were placed by either suprapubic or transvaginal approach, per surgeon's preference. Demographics and intraoperative data on preoperative dose of phenazopyridine and medications linked to voiding dysfunction were captured. One hundred seventy-four subjects were identified. Twenty-five subjects failed to meet inclusion and exclusion criteria and were excluded, and 149 subjects comprised the final groups. Eighty-two subjects (55.03%) received phenazopyridine, and 67 (44.97%) did not. Most subjects received a 200-mg dose (97.6%). Except for surgical approach, both groups receiving and not receiving phenazopyridine had similar demographic characteristics. Eighty-eight percent of the subjects who received phenazopyridine passed the voiding trial versus 73.1% (odds ratio, 2.98; 95% confidence interval, 1.23-7.17). After adjusting for medications, estimated blood loss, number of trocar passages, or bladder perforation, the patients receiving phenazopyridine were still more likely to pass the postoperative voiding trials compared with those who did not (odds ratio, 2.97; 95% confidence interval, 1.10-7.98). Our findings suggest that the preoperative administration of phenazopyridine may improve postoperative voiding function after a retropubic midurethral sling. Additional prospective trials are needed to confirm this finding.

Simple and effective: transvaginal vesico-vaginal fistula repair with a modified Latzko technique.

The incidence of vesico-vaginal fistulas after hysterectomies for benign indications in developed countries is less than one percent. The objective of this video is to demonstrate an easy-to-follow, step-by-step approach to repairing a small, uncomplicated vesico-vaginal fistula transvaginally using a modified Latzko technique. In this video, we present a case of a 46-year-old woman who developed a simple, uncomplicated vesico-vaginal fistula after a total abdominal hysterectomy. To correct her fistula, we used a modified Latzko technique, which is a transvaginal approach to vesico-vaginal fistula repair that involves mobilizing the vaginal mucosa around the fistula and then closing the pubo-vesical fascia and vaginal mucosa in layers. The patient had successful surgical correction of her vesico-vaginal fistula without recurrence of the fistula. For small, uncomplicated vesico-vaginal fistulas, a transvaginal approach has an equivalent success rate to that of other approaches with less invasiveness and faster recovery times. Therefore, it is reasonable to use a modified Latzko technique to help restore the quality of life to women affected by small, uncomplicated vesico-vaginal fistulas.

P01.03: Ultrasound assessment of cervical length and volume: comparison of transabdominal and transvaginal approach

We investigate the reliability of transabdominal (TA) 3D measurements of the cervical volume (CV) by comparison with transvaginal sonography for CV measurement. All singleton pregnancies were included and women who already had a diagnosis of preterm labour, PROM, IIOC in the current pregnancy were excluded. For determination of the CV using VOCAL software. We assessed the correlation of TA and TV measurements. In addition, the discrepancies between TA and TV sonography were analysed to investigate the practical usefulness of TA sonography for the variable maternal and fetal conditions. A paired t test and Pearson correlation were used to compare the two parameters according to approach method. A total of 300 pregnant women were enrolled in this study. The mean GA was 33±3.6 years. The mean CL and CV were 34.5 ± 9.5 cm and 35.1 ± 12.9cm3 on TAS and 33.5 ± 9.7 cm and 35.1 ± 12.9cm3 on TVS, respectively. There was no significant difference between these means of CL and CV(Pearson r = 0.76 vs r=0.91, respectively). There are no significant discrepancy between TV and TA measurement of both parameter for the variable fetal and maternal condition; fetal presentation, maternal abdominal wall thickness, bladder filling state, maternal age, amniotic fluid index. Preterm birth group (N=16, 7.4%) had more shorter and smaller TV CL, CV(30.0 ± 12.1mm vs 34.0 ± 0.93mm, p 0.01 and 29.30 ± 9.3 cm3 vs 35.47 ± 13.14 cm3 p 0.03, respectively) than term birth group. CV measurement did not add any benefit compared with the CL measurement for prediction of preterm birth. But in subgroup analysis, CV measurement had additional benefit compared with the CL for prediction of preterm birth in normal cervical length group. In conclusion, the evidence for the clinical application of cervical volume screening is still insufficient. If TA CL is normal, it could be useful to try the TACV measurement. This step-by-step approach may be more convenient and useful to both patients and physicians for cervical length screening.

Contemporary Modalities to Image the Fetal Brain.

Fetal brain ultrasound remains as the mainstay for screening fetal intracranial anatomy. One of its main advantages is the availability of 3 dimensional and other ultrasound modalities for a better understanding of fetal neurodevelopment. Neurosonography is performed when findings, suggestive of an abnormality, are present on a screening ultrasound or if a high-risk situation of brain injury is present. This technique offers the use of complementary imaging planes, axial, coronal and sagittal, and the ability to image intracranial anatomy from the transabdominal and transvaginal approaches. Fetal brain magnetic resonance imaging is more sensitive than ultrasound. As an adjunctive imaging modality, magnetic resonance imaging offers additional sequences to complete the information on neurodevelopment from different perspectives, such as brain metabolism, microstructure, and connectivity.

EP02.02: Ventricular wall morphology in cases with mild/moderate ventriculomegaly at 18–21 weeks

It is a hard task to predict subsequent course in cases of mild-moderate ventriculomegaly(VM) with atrial width (AW) of 10-15 mm between 18 and 21weeks. It might resolve spontaneously in several weeks with favourable prognosis, and it might be associated with cerebral maldevelopment such as migration disorder. For proper management and counselling, it is required to differentiate those with or without favourable prognosis. Close observation by transvaginal 3D approach of ventricular wall morphology may be useful. Five cases of mild/moderate VM at 18-21 weeks gestation in our institute between 2010 and 2016 were retrospectively investigated. We studied ventricular morphology findings by transvaginal high-frequency 3D ultrasonography and subsequent outcome/prognosis or autopsy findings. Amniotic cell microarray was normal in all cases. In 2 cases with good prognosis, the ventricular wall was extremely smooth, and MVM was normalised promptly in the time course. One out of three cases with ventricular wall irregularity selected abortion and autopsy revealed multifocal nodular heterotopia which is considered to lead a very poor prognosis. Two cases continued pregnancy, but in one case, a migration disorder which is obvious in subsequent diagnostic imaging has been found out. We investigate exosome analysis in migration abnormal cases. It is extremely difficult to predict postnatal prognosis in cases of mild/moderate VM. It is suggested that it might be possible to predict unfavourable prognosis accompanying with migration disorder by close observation of ventricular wall morphology.

Application of synthetic and biological implants for fixation of rectovaginal septum in rectocele repair

OBJECTIVE. Comparative assessment of results was made in application of synthetic and biological implants for rectocele repair. MATERIAL AND METHODS. The patients (n = 61, aged 34-61 years old) underwent operation concerning an isolated rectocele at the period from 2012 to 2015. Diamond-shaped plasty was performed using transvaginal approach. Synthetic composite mesh was used in 33 patients of the first group and biologic implant was applied in 28 women of the second group. RESULTS. Defecography showed reduction of middle size of rectocele in both groups in term of one year after surgery. However, the difference was insignificant in patients with biological implants. According to individual comparative analysis, the patients (n =9 (32,1 %) of the second group had the same size of rectocele as it was in preoperative period, but only 3 (9,1 %) patients of the first group had the same proportion. CONCLUSIONS. The anatomic results were significantly worse after application of biological implants, which appeared to be less reliable.

TAUS versus TVUS in detection early pregnancy complication

Background:Using TVUS(transvaginal ultrasound ) visualization of pelvic organ is limited due to attenuation of ultrasound beam byintervening anterior abdominal wall and pelvic fat while TVUS (high frequency transducers 5-7MHz) now day regard important revolution in diagnosis of early pregnancy and their complications ,because it facilitate high resolution image of target organ uterus , adenaxa and cul de sac.Aim of study:To evaluate TVUS in detection of early pregnancy complication and compare transvaginal approach with TAUS . Patient and Methods :Sixty four patients were included in this study all of them have positive pregnancy test with signs and symptoms of early pregnancy complication .All of those patient examine by TAUS than by TVUS .with good explanation of the procedure to the patients .Results:From sixty four patients a twenty five patients has normal intrauterine pregnancy all of them are diagnosed by TVUS while only 12 diagnosed by TAUS.Five patients have blighted ova all of them are diagnosed by TVUS and only 2 diagnosed by TAUS. All of 6 patient with subchronic hematoma are diagnosed by TVUS only 4 diagnosed by TAUS . Three cases were diagnosed as ectopic pregnancy and all of them are diagnosed by TVUS only 1 diagnosed by TAUS . Two patient that diagnosed only by TVUS had intact gestational sac in the adenaxa with positive heart pulsation in fetal pole.Incomplete abortion diagnosed in 8 patient all of them diagnosed by TVUS , only 3 diagnosed by TAUS Fourteen patients has missed abortion only 8 of them are diagnosed by TAUS .Conclusion and Recommendation:TVUS is more sensitive and more accurate in diagnoses of normal early pregnancy and in detection of early pregnancy complication.Many patient refused TVUS. So good explanation of the procedure to the patient is important.

Robotic Sacrocolpopexy-Is It the Treatment of Choice for Advanced Apical Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) is a highly prevalent condition among women that, although non-life threatening, can significantly impact daily activities and quality of life (QOL). Sacrocolpopexy (SC) has been touted by many as the "gold standard," citing superior anatomic success rates compared to transvaginal approaches for apical prolapse repair. In line with current trends throughout the surgical field, robotic-assisted laparoscopic sacrocolpopexy (RSC) has rapidly gained popularity. This review will present the most contemporary evidence examining RSC and discuss whether it has met criteria to qualify as the "treatment of choice" for advanced apical vaginal prolapse. Recent findings support the superior durability of SC for apical prolapse repair compared to native tissue vaginal approaches. Recent evidence demonstrates that anatomic outcomes of minimally invasive sacrocolpopexy, including RSC, are no different than those of traditional ASC. Low quality evidence suggests lower rates of dyspareunia with SC compared to vaginal repairs. RSC may be cost-effective when compared to ASC. When compared to LSC, however, RSC is more expensive and associated with longer operating times. RSC is an excellent option for many women who desire the most durable option for definitive repair of advanced apical POP.

Sphincter-saving extrasphincteric rectal dissection and proximal segmental sphincteric excision techniques by using combined abdominal and transvaginal anterior perineal access in female patients who have lower rectal cancer (Transvaginal low anterior rectal resection)

BackgroundCombined abdominal and transvaginal anterior perineal approaches have been used as an alternative surgical method for the surgical treatment of the lower rectal cancer. The main aim of this paper is to describe the surgical stages of the combined abdominal and transvaginal approaches performed for lower rectal cancer, especially in transvaginal anterior perineal stage. MethodWe have performed sphincter-saving surgical operations by using transvaginal anterior perineal access by combining with the abdominal access in four female patients who had lower rectal cancer. ResultsSphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques were performed in four female patients operated with combined abdominal and transvaginal anterior perineal approach. All patients were found to have continence. Postoperatively, one patient was converted to abdominoperineal rectal amputation due to the detected distal resection margin positivity. ConclusionTransvaginal anterior perineal access provides the extrasphincteric rectal dissection possibility in the ischioanal fossa. Therefore, the combined abdominal and transvaginal anterior perineal approaches have been based on the different anatomical and surgical features when compared to intersphincteric dissection technique which is the most common used surgical procedure in lower rectal cancer surgery.

State of the Art for Treatment of Vesicovaginal Fistula.

Vesico-vaginal fistulae (VVF) remain the most prevalent genitourinary fistula detrimentally impacting quality of life. The purpose of this review is to examine relevant literature on management of VVF. Obstructed labor is the leading cause of VVF in the developing world with most repairs performed via the transvaginal approach. Conversely, the predominate etiology in industrialized nations is iatrogenic injury with an increasing trend towards abdominal repair via a minimally invasive (laparoscopic and robotic) approach. No studies have compared transvaginal repair to minimally invasive transabdominal approaches. Further, an increasing number of authors have developed algorithms to determine optimum surgical approaches and risk factors for persistent incontinence. As surgeons become more facile with laparoscopic and robotic skills, there is a growing trend for minimally invasive surgical management of VVF in developed countries, perhaps widening the disparity gap between developing nations where transvaginal approaches predominate with good success. Further studies are needed to compare transvaginal to minimally invasive transabdominal approaches.

Vaginal Sacral Colpopexy: A Natural Orifice Approach to a Gold Standard Procedure

Study ObjectiveA transvaginal approach to sacral colpopexy has a natural appeal to those interested in minimally invasive pelvic reconstructive surgery. Development of an effective technique has been frustrated because of the technical difficulty of confining the dissection and placement of mesh to the retroperitoneal space. The objective of this prospective study is to describe the technique and report the outcomes of a transvaginal, retroperitoneal sacral colpopexy. DesignProspective cohort study (Canadian Task Force Design classification II-2). SettingUrogynecology of Southern Alabama private practice. PatientsWomen with stage 2 or greater apical prolapse. InterventionsSurgical repair of apical prolapse using vaginal sacral colpopexy. Measurements and ResultsOver a 1-year period, 15 posthysterectomy patients with stage 2 or greater vaginal prolapse were recruited and consented to vaginal sacral colpopexy. Primary outcome was success of the repair, with success defined as a combination of objective and subjective parameters using pelvic organ prolapse quantification measures, and quality of life questionnaires. Secondary outcomes were complications and operating time. One case converted to a native tissue repair. The vaginal sacral colpopexy was completed in the remaining 14. Eleven patients have been followed for 1 year or longer. Two patients did not return after their 6-week examination because of chronic illness. They were contacted by telephone over 2 years after the surgery and expressed total satisfaction with the operation and the outcome. One patient was seen at 3 months and was noted to have an excellent anatomic result; however, a pelvic organ prolapse quantification evaluation was not done. She has been totally lost to further follow-up. There was 1 mechanical failure in which the titanium tacks securing the apex to the anterior longitudinal ligament dislodged and a second case with a stage 2 posterior compartment defect. One incidental cystotomy, and 1 incidental proctotomy occurred. These were both small, remote from the site of the vaginal mesh, and did not prevent completion of the procedure. There were no mesh-related complications. Mean operating time was 123 minutes. ConclusionIn this small pilot study, a transvaginal retroperitoneal sacral colpopexy is described and is demonstrated to be feasible and safe. Based on the experience gained, changes in technique have been implemented to prevent future mechanical tack failures. Assuming that these changes will be successful in preventing apical recurrence due to dislodgement of mesh from the anterior longitudinal ligament, a larger study is planned to determine efficacy. Inherent advantages of the transvaginal approach are discussed, including a favorable morbidity profile, full access to all compartments, short operating times, and decreased costs.

Three-dimensional neurosonography - a novel field in fetal medicine.

Neurosonography is a promising technique for prenatal diagnosis, combining features of ultrasound imaging with fetal neurology. The brain is a three-dimensional structure, therefore observing brain structure in the three basic planes (sagittal, coronal and axial) is mandatory. The anterior fontanelle and sagittal suture may serve as acoustic ultrasound windows in the transvaginal brain scan, allowing to obtain high-resolution neuroimages of the intracranial structures. Furthermore, three-dimensional (3D) ultrasound combined with the transvaginal brain approach provides detailed and sophisticated neuroimages. Three orthogonal planes of the brain, tomographic ultrasound imaging (TUI) and other off-line approaches (e.g. volume contrast imaging (VCI) or HDlive silhouette imaging) may be obtained from a single 3D dataset. 3D Doppler ultrasound enables visualization of the intracerebral vascularity, allowing to obtain more precise information on cerebral perfusion. Various abnormal brain conditions, including ventriculomegaly, agenesis of the corpus callosum, posterior fossa abnormalities and others, can be well-demonstrated. Due to high rates of the associated anomalies and uncertain prognosis, any suspicion of CNS abnormalities shall imply detailed ultrasonographic evaluation of the fetal anatomy to exclude the associated anomalies. Despite a growing number of neuroimaging modalities, prenatal counselling remains a challenge as prediction of brain functionality and the neurological prognosis often remain uncertain. New investigations on the relations between various migration disorders and gene mutations, as well as recent clinical research on the relations between neuroimaging detection of local migration disorders using sophisticated imaging technologies and the postnatal neurological prognosis will contribute to the development of maternal-fetal medicine as well as pediatric neurology.

Transvaginal Excision of an Eroded Sacrocolpopexy Mesh by Using Single-Incision Laparoscopic Surgery Equipment

Study ObjectiveTo show a new technique of using single-incision laparoscopic surgery (SILS) equipment in vaginal surgery to create a “pneumovagina.” DesignExplanatory video demonstrating the technique and intraoperative findings. SettingUniversity hospital. PatientThe 68-year-old patient was referred with a vaginal mesh erosion that resulted in abscess formation at the vaginal apex. The patient was symptomatic with an increasingly foul-smelling vaginal discharge for about 1 year. She had a laparoscopic sacrocolpopexy in a remote hospital 22 months before the current operation and had a total abdominal hysterectomy 15 years ago. The, patient's history was uneventful without dyspareunia, incontinence or voiding difficulties, and she was otherwise content with the sacrocolpopexy result. The local institutional review board granted exemption for this publication. InterventionFrequently, pelvic organ prolapse can only be effectively treated if the surgical procedure comprises support of the central compartment. Laparoscopic sacrocolpopexy shows superior outcomes for this indication, with success rates of up to 96%. However, a rare side effect of laparoscopic sacrocolpopexy is mesh erosion, occurring in up to 2.4% [1]. These erosions are usually treated laparoscopically [2]. In this video we show an alternative route for excision of a symptomatic exposed mesh by using a transvaginal approach: The SILS trocar is used vaginally for abscess irrigation and mesh excision with minimally invasive instruments. Measurements and Main ResultsFor treatment of the abscess and removal of the exposed mesh, the SILS trocar was placed vaginally, and laparoscopic instruments were used. The abscess was incised, cleansed and irrigated, debrided, and the mesh excised. Because no mesh material was exposed after excision, the vagina was not closed to avoid creating a cavity with the risk of promoting reabscess formation, and secondary wound healing was anticipated. Laparoscopy was used to confirm that no intra-abdominal lesion coexisted or occurred. There were no signs of further infection of the residual mesh beyond the area exposed in the vagina. The patient's only symptom was foul-smelling discharge, but no back pain or signs of systemic inflammation were found. Knowing that foreign body (mesh) infection usually needs to be treated by complete mesh removal, we did not have any clues of distant mesh infection and counseled the patient that if reinfection occurred a second surgery might be necessary. Nevertheless, we treated this patient with abscess drainage and removal of large parts of the mesh. Thus, the operation was not extended to a complete mesh excision to prevent major surgery and the risk of recurrent prolapse. Particularly, the area of the mesh excision was inspected with the rendezvous technique (light source vaginally, laparoscopic pelvic view with laparoscopic light source switched off) to identify the area of mesh excision from the intra-abdominal area. Sigmoid and rectum were distant to this area, suggesting that no bowel lesion occurred. No complications occurred in the postoperative course. In the follow-up visit 6 months postoperatively the patient was asymptomatic, and the vaginal examination was uneventful with no recurrent erosion. Although improved oversight and richness of detail achieved by the vaginal SILS method is helpful in patients like our case with a suspended vaginal vault, its costs need to be balanced against conventional vaginal approaches (e.g., use of a Lonestar retractor). ConclusionThe SILS trocar and laparoscope used (SILS Port; Covidien, New Haven, CT) vaginally provide a magnificent and detailed view to allow for exact preparation by means of microinvasive instruments in vaginal surgery, even more in patients with a suspended vaginal vault where access to the apex can be tricky. The “pneumovagina” created by CO2 insufflation further helps to expose the vaginal apex. The rendezvous technique can additionally be used to identify intra-abominal lesions.

MP36-10 URETHROVAGINAL FISTULA REPAIR: LONG-TERM OUTCOMES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I1 Apr 2017MP36-10 URETHROVAGINAL FISTULA REPAIR: LONG-TERM OUTCOMES Sender Herschorn Sender HerschornSender Herschorn More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1121AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethrovaginal fistula (UVF) is not highly prevalent in urologic practice but merits attention. There are few large published series. This is a review of management of all patients that have been treated over a 30-year period at our institution to assess etiology, operative management, and outcomes. METHODS Between 1986 and 2016, a total of 36 UVFs were repaired. Retrospective review recorded presentation, history, etiology, surgical approach, and results. Long-term lower urinary tract symptoms (LUTS) were noted. All UVFs were closed in 3 or more layers. A variety of flaps were used as needed. A suprapubic or foley catheter was left indwelling for 3-4 weeks and healing was assessed by cystourethrogram. RESULTS Mean patient age was 49.2 (range 21-81). 13 (36%) were long-time smokers. 8 patients had a history of urethral diverticulum and 3 had previously treated pelvic malignancies. All patients had prior pelvic surgery. The most common etiology was an incontinence procedure in 13 patients (36%) with mesh erosion in 6 of these. Other causes were urethral diverticulum repair in 7 (19.4%), forceps delivery in 5 (14%), self-intermittent catheterization in 3 (8%), cystectomy and neobladder in 2 (6%), and other vaginal procedures in 6 (17%). Incontinence was the primary complaint in 33 women and the diagnosis was made on cystoscopy in 34. Thirty-four (94%) were closed via transvaginal approach including 15 with simultaneous rectus fascia pubovaginal slings harvested through an abdominal incision. Two were approached transabdominally, and 1 was closed with a combined abdominal and vaginal approach. Thirteen repairs were done with flaps including Martius in 11 and omentum in 2. Mean hospital stay was 3.9 days (range 0.5-10). The overall repair success rate was 34/36 (94%). Mean follow-up time was 41.2 months (range 0.8-207.33). Long-term LUTS included frequency in 11 patients (31%), urgency in 10 (28%), urgency incontinence in 9 (25%), and stress incontinence in 6 (17%). Foley catheter drainage replaced suprapubic drainage in the past 10 years but did not change outcomes. Two recurrences (1 neobladder and 1 post-ileocystoplasty) occurred immediately and underwent continent diversion. CONCLUSIONS UVFs usually result from a surgical complication. Smoking may be a risk factor. Management techniques that optimized outcomes included multi-layer closure usually with flaps and/or rectus fascial sling, extended catheter drainage, and tailoring the repair to the problem. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e469 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Sender Herschorn More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...