Vaginal Approach Research Articles

Cesarean scar disorder: Management and repair.

Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.

Other treatments for CSP.

Caesarean scar pregnancy (CSP) is an increasingly common clinical conundrum. The non-curettage surgical management of CSP can be categorised into hysteroscopic, vaginal, laparoscopic, and open removal modalities and the choice of treatment is surgeon-dependent. A systematic review of original studies reporting surgical treatment outcomes of CSP until March 2023 was conducted to evaluate the non-curettage surgical management of this highly morbid condition. A total of 60 studies of mostly weak methodological quality were identified involving 6720 CSP cases. Success rates were generally high across all treatment modalities although highest in vaginal and laparoscopic excisional approaches. Morbidity was most associated with haemorrhage although unplanned hysterectomy rates remained low across all treatment groups. Subsequent pregnancies are associated with morbidity despite being underreported and the impact of CSP treatment on future pregnancy is poorly understood. Substantive study heterogeneity precludes meta-analyses of pooled data and treatment superiority has not been demonstrated.

Survival outcomes of abdominal radical hysterectomy, laparoscopic radical hysterectomy, robot-assisted radical hysterectomy and vaginal radical hysterectomy approaches for early-stage cervical cancer: a retrospective study

BackgroundThis study compared the survival outcomes of abdominal radical hysterectomy (ARH) (N = 32), laparoscopic radical hysterectomy (LRH) (N = 61), robot-assisted radical hysterectomy (RRH) (N = 100) and vaginal radical hysterectomy (VRH) (N = 45) approaches for early-stage cervical cancer to identify the surgical approach that provides the best survival.MethodsDisease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan–Meier method, and survival curves were compared using the log-rank test.ResultsThe volume of intraoperative blood loss was greater in the ARH group than in the LRH group, the RRH group or the VRH group [(712.50 ± 407.59) vs. (224.43 ± 191.89), (109.80 ± 92.98) and (216.67 ± 176.78) ml, respectively; P < 0.001]. Total 5-year OS was significantly different among the four groups (ARH, 96.88%; LRH, 82.45%; RRH, 94.18%; VRH, 91.49%; P = 0.015). However, no significant difference in 5-year DFS was observed among the four groups (ARH, 96.88%; LRH, 81.99%; RRH, 91.38%; VRH, 87.27%; P = 0.061).ConclusionThis retrospective study demonstrated that ARH and RRH achieved higher 5-year OS rates than LRH for early-stage cervical cancer.

EFFECTIVENESS OF SYNTHETIC IMPLANTS FOR GENITAL PROLAPSE SURGERY

The aim of the study is to evaluate the effectiveness of synthetic implants for genital prolapse surgery in women of different age groups.&#x0D; Materials and Methods. 139 patients underwent genital prolapse surgery, vaginal approach, with synthetic mesh and biologic grafts. For the anterior, posterior and complete reconstruction of the vaginal walls, two mesh implants were used: Pelvix (Lintex, Russia) and Prolift (Ethicon Women´s Health and Urology, Johnson and Johnson Company, USA). The size of mesh implant was adapted to each particular case.&#x0D; Results. The most common intraoperative complication was intraoperative blood loss. During pelvic floor reconstruction with mesh implants, it was 1.8 times and 1.5 times higher in reproductive age and perimenopause respectively, compared with grafts. In postmenopause, there was a tendency to greater blood loss in surgeries with biological grafts. In reproductive age, the frequency of early postoperative complications was the same for mesh and non-mesh repair. In perimenopause, complications were three times more often for mesh repair, and in postmenopause, complications were observed in every third examined patient, regardless of the repair used. Late postoperative complications (pelvic pain and dyspareunia) occurred more often for biological graft: in reproductive age – twice, in perimenopause – 1.5 times, and in postmenopause – 5 times as frequently as for mesh.&#x0D; Conclusion. Prolapse surgery with synthetic implants is effective, safe and justified in terms of pathogenesis.

Laparoscopic uterosacral ligament suspension: a systematic review and meta-analysis of safety and durability.

Pelvic organ prolapse (POP) is a widespread condition affecting from 40% to 60% of women. Reconstructive vaginal surgeries are the most commonly performed procedures to treat POP. Among those, uterosacral ligament suspension (USLS), which is usually performed transvaginally, preserves pelvic statics and dynamics and appears to be an effective method. Laparoscopic USLS is a valid alternative to vaginal approach, and the aim of our review is to confirm its safety and feasibility and to compare clinical outcomes among the procedures. Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed and Scopus databases in December 2022. We made no restriction on the publication year nor on the country. Data about POP-Q recurrence rate (RR), intraoperative and postoperative complications (graded according to Clavien-Dindo classification), readmission rate, and reoperation rate were collected and analyzed. We used comparative studies for meta-analysis. A total of nine studies fulfilled inclusion criteria: two articles were non-comparative retrospective observational studies, three more articles were comparative studies where laparoscopic USLS was confronted with other surgical techniques (only data of laparoscopic USLS were analyzed), and four were comparative retrospective cohort studies between laparoscopic and vaginal USLS procedures. The comparative studies were enrolled in meta-analysis. Patients were analyzed concerning perioperative risks and the risk of recurrence. The meta-analysis highlighted that there was no clear inferiority of one technique over the other. Laparoscopic USLS is a technique with a low complication rate and low recurrence rate. Indeed, laparoscopic procedure allows better identification of anatomical landmarks and access to retroperitoneum. Moreover, efficacy over time and durability of Laparoscopic (LPS) USLS was also observed. However, these data should be weighed in light of the length of follow-up, which was in a very short range. Further, focused and prospective studies will be necessary to confirm this finding.

Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020.

The objective of this study was to determine the trends in surgical approach to hysterectomy over the last decade and compare perioperative outcomes and complications. This retrospective cohort study used clinical registry data from the Michigan Hospitals that participated in Michigan Surgical Quality Collaborative (MSQC) from January 1st, 2010 through December 30th, 2020. A multigroup time series analysis was performed to determine how surgical approachto hysterectomy [open/TAH, laparoscopic (TLH/LAVH), and robotic-assisted (RA)] has changed over the last decade. Abnormal uterine bleeding, uterine fibroids, chronic pelvic pain, pelvic organ prolapse, endometriosis, pelvic mass, and endometrial cancer were the most common indications for hysterectomy. The open approach to hysterectomy declined from 32.6 to 16.9%, a 1.9-fold decrease, with an average decline of 1.6% per year (95% CI - 2.3 to - 0.9%). Laparoscopic-assisted hysterectomies decreased from 27.2 to 23.8%, a 1.5-fold decrease, with an average decrease of 0.1% per year (95% CI - 0.7 to 0.6%). Finally, the robotic-assisted approach increased from 38.3 to 49.3%, a 1.25-fold increase, with an average of 1.1% per year (95% CI 0.5 to 1.7%). For malignant cases, open procedures decreased from 71.4 to 26.6%, a 2.7-fold decrease, while RA-hysterectomy increased from 19.0 to 58.7%, a 3.1-fold increase. After controlling for the confounding variables age, race, and gynecologic malignancy, RA hysterectomy was found to have the lowest rate of complications when compared to the vaginal, laparoscopic and open approaches. Finally, after controlling for uterine weight, black patients were twice as likely to undergo an open hysterectomy compared to white patients.

Surgical outcomes of intraabdominal versus vaginal approach for uterine manipulation during total laparoscopic hysterectomy.

Uterine manipulation is essential for moving the uterus and proper anatomical dissection without complications during total laparoscopic hysterectomy (TLH). Although many different uterine manipulators (UM) have been designed in the last few decades, there is still no "optimal UM" that is universally safe, efficient, and cost-effective. This study aimed to compare myoma screw (MS) and UM with regard to surgical outcomes and cost-effectiveness in patients who underwent TLH. In the current study, we describe an operation technique that uses a MS instead of a uterine manipulator during TLH and discuss the surgical outcomes of this method. The use of MS resulted in significantly shorter operation time with respect to UM for uterine manipulation during TLH regarding benign indications, with affordable costs. The use of MS is a safe and cost-effective alternative to the use of UM during TLH.

Comparison of Early Postoperative Outcomes for Vaginal Anterior Sacrospinous Ligament Fixation with or without Transvaginal Mesh Insertion.

Pelvic organ prolapse affects one in three women, and cystocele accounts for 80% of the indications for surgery. Following the withdrawal of transvaginal mesh from the market, the objective of the present before-and-after study was to compare of the previous reference technique (UpholdTM (Boston Scientific, Marlborough, MA, USA) mesh insertion) with anterior sacrospinous ligament fixation with suturing in terms of the outcomes 2 months after surgery. We performed a retrospective, observational, before-and-after study at Lille University Medical Center (Lille, France) by including consecutive patients operated on between 2011 and 2018 for UpholdTM mesh insertion and between 2018 to 2020 for anterior sacrospinous ligament fixation. The primary outcome was the early recurrence of prolapse, and the secondary outcomes were the occurrence of early per-operative or post-operative complications and the development of de novo stress urinary incontinence. Here, 466 patients were included in the study (382 in the UpholdTM group and 84 in the anterior sacrospinous ligament fixation group). The failure rate at 2 months was 6.0% (5 out of 84) for anterior sacrospinous ligament fixation and 1.3% (5 out of 382) for UpholdTM (p < 0.01). The prevalence of acute urinary retention was significantly lower in the anterior sacrospinous ligament fixation group (3.6%) than in the UpholdTM group (14.1%; p < 0.01), as was the de novo stress urinary incontinence rate (11.9% vs. 33.8%, respectively; p < 0.01). Anterior sacrospinous ligament fixation appears to be an effective, safe alternative to mesh insertion in the management of cystocele via the vaginal approach; the early complication rate was slightly lower, but the early failure rate was slightly higher.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Global increased cesarean section rates and public health implications: A call to action.

Over the years; global caesarian section (CS) rates have significantly increased from around 7% in 1990 to 21% today surpassing the ideal acceptable CS rate which is around 10%-15% according to the WHO. However, currently, not all CS are done for medical reasons with rapidly increasing rate of nonmedically indicated CS and the so-called "caesarian on maternal request." These trends are projected to continue increasing over this current decade where both unmet needs and overuse are expected to coexist with the projected global rate of 29% by 2030. CS reduces both maternal and neonatal morbidity and mortality significantly when it is done under proper indications while at the same time, it can be of harm to the mother and the child when performed contrary. The later exposes both the mother and the baby to a number of unnecessary short and long-term complications and increase the chances of developing different noncommunicable diseases and immune-related conditions among babies later in life. The implications of lowering SC rate will ultimately lower healthcare expenditures. This challenge can be addressed by several ways including provision of intensive public health education regarding public health implications of increased CS rate. Assisted vaginal delivery approaches like the use of vacuum and forceps and other methods should be considered and encouraged during delivery as long as their indications for implementation are met. Conducting frequent external review and audits to the health facilities and providing feedback regarding the rates of CS deliveries can help to keep in check the rising CS trends as well as identifying the settings with unmet surgical needs. Moreover, the public especially expectant mothers during clinic visits and clinicians should be educated and be informed on the WHO recommendations on nonclinical interventions towards reduction of unnecessary CS procedures.

Racial Disparities in Vaginal Hysterectomy Postoperative Outcomes: Trends Using the NSQIP Database [ID: 1377940

INTRODUCTION: Vaginal hysterectomies (VHs) are associated with superior outcomes in operative time, postoperative complications (PCs), and recovery, and thus VH is often the preferred approach whenever feasible. Racial disparities have previously been described for abdominal and laparoscopic hysterectomies, but not for the vaginal approach. The purpose of this study was to disaggregate racial data and evaluate variation in VH surgical outcomes by race. METHODS: The National Surgical Quality Improvement Program was queried to identify all VHs from 2011 to 2020 in the National Surgical Quality Improvement Project (n=59,469). Multivariable regression models were used to investigate the effect of race on 30-day PCs and same-day discharge (SDD). RESULTS: Compared to non-Hispanic White patients and other minority groups, American Indians and Alaskan Natives (AI/AN) had 2.6% higher odds of PC (adjusted odds ratio [AOR] 1.026, 95% CI 1.002–1.050) and 6.2% lower odds of SDD (AOR 0.938, 95% CI 0.911–0.965). Non-Hispanic Black patients had 1.1% higher odds of PC (AOR 1.011, 95% CI 1.003–1.020). Paradoxically, Native Hawaiian and Pacific Islander (NH/PI), Asian, and Hispanic patients had 30.9%, 18.7%, and 3.3% higher odds of SDD, respectively, without statistically significant increased odds of PC. CONCLUSION: AI/AN and Black patients were more likely to have a PC, while NH/PI, Asian, and Hispanic patients were more likely to have SDD without significantly higher odds of PC. Given these findings, it may be reasonable to encourage the VH approach especially in the NH/PI, Asian, and Hispanic patient populations.

The estriol use in the perioperative period by patients with genital prolapse

Introduction. Postmenopausal women in a state of oestrogen deficiency often experience pelvic prolapse with underlying genitourinary menopausal syndrome, when the progression of atrophic processes in the vaginal mucosa comes to the forefront.Aim. To evaluate the results of the use of topical hormonal therapy in the perioperative period to improve the vaginal epithelial surface appearance in postmenopausal women who need surgical treatment of pelvic prolapse.Materials and methods. A comparative prospective randomized clinical trial included 60 postmenopausal patients aged 60 to 69 years with a postmenopausal period of 10 to 20 years, suffering from POP-Q stage II–IV pelvic prolapse (ICS, 1996). All patients were recommended surgical treatment using vaginal approach. The treatment group (Group 1) included 30 patients who received topical hormonal therapy with an estriol drug (Ovestin cream, 1 mg/g) within 1 month before reconstructive plastic surgery. The comparison group (Group 2) included 30 patients who did not receive hormonal treatment in the perioperative period.Results. No complications were observed in the treatment group after reconstructive plastic surgery in the early and late postoperative periods. In the comparison group, natural urination was not achieved in 9 of 30 (35.0%) women on Day 2 after surgery, in 4 of 30 (13.3%) patients on Day 3. Also in that group, 4 of 30 (13.3%) patients experienced infectious and inflammatory complications in the postoperative period, the mucous membrane healing in 5/30 (16.6%) patients took a long time, over 1 month.Conclusions. The use of topical hormonal therapy with an estriol drug in the perioperative period in patients who require surgical treatment of pelvic prolapse results in the relief of vulvovaginal atrophy symptoms and adequate regeneration of the vaginal mucosa, which helps reduce the likelihood of complications in both early and late postoperative periods.

Radical Vaginal Hysterectomy, Type B: An Educational Video, Cadaver Model.

The radical vaginal hysterectomy popularized by Schauta1 has been virtually abandoned due to painful perineal incision, high rate of urinary dysfunction, and inability to perform lymph node assessment. However, this approach is still used and taught in a few centers outside its Austrian birthplace. In addition, a combined vaginal and laparoscopic approach, overcoming the flaws of the pure vaginal technique, was developed in the 1990s by French and German surgeons.2 After the publication of the Laparoscopic Approach to Cervical Cancer trial,3 the radical vaginal approach has found a very timely application with the closure of the vaginal cuff, aiming at avoiding cancer cell spillage.4 In addition, it is the basis to perform radical vaginal trachelectomy, or Dargent's operation, the best documented approach for the fertility-sparing management of stage IB1 cervical cancers. Today, the main obstacle to the rebirth of radical vaginal surgical surgery is the lack of teaching centers and the need of a specific learning curve that requires performing 20-50 surgeries.5,6 This educational video demonstrates that training is possible using a fresh cadaver model. A type B approach according to the Querleu-Morrow7 classification of radical vaginal hysterectomy, adapted according to surgeon's choice to stage IB1 or IB2 cervical cancer, is shown. Key specific steps such as the creation of a vaginal cuff and the identification of the ureter within the bladder pillar are highlighted. Fresh cadaver model is a method that spares the patients the risks of early learning curve while allowing the surgeon to acquire skills and keep offering the patient the benefit of the most specifically gynecological approach in cervical cancer surgery.

MP42-18 ROBOT-ASSISTED VESICO-VAGINAL FISTULA REPAIR: COMPARISON OF THE EXTRAVESICAL AND TRANSVESICAL TECHNIQUES

You have accessJournal of UrologyCME1 Apr 2023MP42-18 ROBOT-ASSISTED VESICO-VAGINAL FISTULA REPAIR: COMPARISON OF THE EXTRAVESICAL AND TRANSVESICAL TECHNIQUES Pierre Lecoanet, Thibault Tricard, Anne Mauger De Varennes, Camille Haudebert, Juliette Hascoet, Nicolas Hubert, Imad Bentellis, Branwell Tibi, Christian Saussine, Jacques Hubert, and Benoit Peyronnet Pierre LecoanetPierre Lecoanet More articles by this author , Thibault TricardThibault Tricard More articles by this author , Anne Mauger De VarennesAnne Mauger De Varennes More articles by this author , Camille HaudebertCamille Haudebert More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , Nicolas HubertNicolas Hubert More articles by this author , Imad BentellisImad Bentellis More articles by this author , Branwell TibiBranwell Tibi More articles by this author , Christian SaussineChristian Saussine More articles by this author , Jacques HubertJacques Hubert More articles by this author , and Benoit PeyronnetBenoit Peyronnet More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic vesico-vaginal fistula repair (R-VVF) was described in 2004 with the aim to minimize the morbidity of the abdominal VVF repair. Almost two decades later, the literature on r-VVF remains scant. The objective of this study was to evaluate the results of R-VVF repaisr and to report complications. METHODS: The charts of all female patients who underwent a R-VVF from March 2007 to December 2021 at four academic institutions were reviewed retrospectively. All surgeons involved had already a robust robotic surgery experience at the beginning experience (>50 cases) but limited experience with VVF repair. All abdominal VVF repair over the study period were performed using a robotic approach. All centers used a vaginal approach in case of easily accessible vaginal fistulous orifice. The decision to use a vaginal or an abdominal approach was not standardized across centers and left at the surgeons’ discretion. The patients’ characteristics, the surgical technique details (iflap interposition vs. not, transvesical versus extravesical approach, excision of fistulous tract vs not) and peri-operative outcomes were recorded. The success of VVF-R was defined as the absence of clinical recurrence. The outcomes of the extravesical vs transvesical techniques were compared. RESULTS: Twenty-two patients were included over the study period. The median age was 43 years (IQR 38-50). The causes of VVF-R were either post-surgical (77.3%), post-obstetrical (18.2%) or post-trauma (4.5%). Fistulas were supratrigonal and trigonal in 18 and 4 cases respectively. The fistulous tract was systematically excised and an interposition flap was used all but two cases (90.9%%). The transvesical and extravesical techniques were used in 13 and 9 cases respectively. The patient andfistula’s characteristics are presented in Table 1. There were more supratrigonal fistula in the extravesical group (100% vs. 69.2%; p=0.11). One intraoperative complication occurred in the extravesical group: an ureteral injury which was immediately sutured (11.1% vs. 0%; p=0.41). The operative time tended to be shorter in the extravesical group (179 vs. 229 minutes; p=0.13). There were only three postoperative complications, all minor: one gross hematuria in the extravesical group (Clavien grade 1), one hematoma requiring blood transfusion and one pyelonephritis in the transvesical group (both Clavien grade 2) (11.1% vs. 15.4%; p=0.99). The length f hospital stay did not differ significantly between the to groups (5.1 vs. 4.1 dys; p=0.56). None of the patients had vesico-vaginal fistula recurrence after a median follow-up of 14 months (IQR 3-21). CONCLUSIONS: The present series, one of the largest R-VVF reported to date, is consistent with the few series already published with a 100% cure rate and excellent perioperative outcomes. Systematic excision of the fistulous tract and the high rate of flap interposition may explain the high success rate. The transvesical and extravesical approach yielded similar outcomes but the transvesical approach may allow to treat more complex fistulas (e.g. infratrigonal). Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e575 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pierre Lecoanet More articles by this author Thibault Tricard More articles by this author Anne Mauger De Varennes More articles by this author Camille Haudebert More articles by this author Juliette Hascoet More articles by this author Nicolas Hubert More articles by this author Imad Bentellis More articles by this author Branwell Tibi More articles by this author Christian Saussine More articles by this author Jacques Hubert More articles by this author Benoit Peyronnet More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-17 INCONTINENCE AFTER SUCCESSFUL ANATOMICAL CLOSURE OF VESICO-VAGINAL FISTULA; INCIDENCE AND MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023MP42-17 INCONTINENCE AFTER SUCCESSFUL ANATOMICAL CLOSURE OF VESICO-VAGINAL FISTULA; INCIDENCE AND MANAGEMENT Amaani Ahmad, Helena Gresty, Anthony Noah, Richard Nobrega, Mahreen Pakzad, Jeremy Ockrim, and Tamsin Greenwell Amaani AhmadAmaani Ahmad More articles by this author , Helena GrestyHelena Gresty More articles by this author , Anthony NoahAnthony Noah More articles by this author , Richard NobregaRichard Nobrega More articles by this author , Mahreen PakzadMahreen Pakzad More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vesicovaginal fistula (VVF) is a rare condition in high resource settings. Significant urinary incontinence (UI) rates have been reported following VVF closure in low resource setting. We have reviewed our VVF series for anatomical closure and post closure UI rates. METHODS: Retrospective review of 132 patients having 1st surgical management of their VVF between 2004-2022. Median age was 51 (16-88) with a median follow-up of 14 months (2-150). Data was collated on demographics, fistula aetiology and characteristics, previous surgery, outcome in terms of anatomical closure and urinary continence, and any requirement for further surgery. Statistical analysis was carried out using chi-squared test, fisher test or students t-test as appropriate. RESULTS: Of the 132 patients identified, 127 (96.2%) had surgery to close their VVF whilst 5 (3.8%) had a primary ileal conduit. Successful anatomical closure was achieved in 118 (93.9%) at 1st attempt. Of the 9 failures, 6 had a 2nd VVF closure attempt, 2 had ileal conduit formation and 1 had recurrent carcinoma and did not proceed to further surgery. Vaginal closure was successful in 95% (97/102) after 1st attempt whilst abdominal closure was successful in 88% (22/25). Of the 6 failures having a 2nd attempt at VVF closure, 3 had an abdominal and 3 had a vaginal approach, with 100% successfully closed. Anatomical closure was confirmed in all patients by cystogram and/or cystoscopy. Of those with successful VVF closure 19 (15.2%) (16 vaginal and 3 abdominal approach) had bothersome post repair UI. This was pre-existing stress urinary incontinence (SUI) in 5 (4%), new onset SUI in 8 (6.4%), pre-existing urgency urinary incontinence (UUI) in 1 (0.8%), new onset UUI in 3 (2.4%) and new onset mixed urinary incontinence (MUI) in 2 (1.6%). 5 (26.3%) (4 with pre-existing SUI) required surgical intervention for management of their SUI (2 colposuspensions and 3 rectus fascial slings) whilst the patient with pre-existing UUI progressed to sacral neuromodulation, with resolution or significant improvement. The remaining 13 (68%) patients experienced resolution or significant improvement of their UI with conservative measures. CONCLUSIONS: Successful anatomical closure of VVF in high resource health care settings can be achieved in 92.9% after 1st repair and 100% after 2nd repair. Post closure bothersome urinary incontinence occurs in 15.2% and resolves with conservative measures in 68%. Surgical interventions for SUI or UUI post closure in 4.8%, with excellent results. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e574 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amaani Ahmad More articles by this author Helena Gresty More articles by this author Anthony Noah More articles by this author Richard Nobrega More articles by this author Mahreen Pakzad More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement PDF downloadLoading ...

Uterine Tube Resection by Vaginotomy as an Alternative to Ovariectomy in Mature Cattle

The prevention of pregnancy is desirable for female cattle destined for sale in the northern Australian rangelands for both economic and welfare reasons. Controlled access to bulls is often not feasible, nor are any non-surgical methods currently available. Many females are therefore surgically spayed. This study describes a technique for uterine tube resection (UTR), which leaves the ovaries intact and is performed using a vaginal approach, and compares the outcomes from 70 Brahman cows subjected to the procedure with 60 heifers spayed using the dropped ovary technique. The animals were monitored for 10 days following the surgery. There were no mortalities, and two animals were treated for illnesses after the UTRs and recovered. The animals subjected to both surgical procedures showed signs of pelvic discomfort and mild inflammation during recovery. The cows gained an average of 9.3 kg (SD 14.5 kg) of weight over the 10 days of the study compared to the spayed heifers, which lost 3.5 kg (SD 13.3 kg), with 19 and 63% of the animals in each of the groups losing weight, respectively. Uterine tube resection can be considered as a viable alternative to surgical spaying.

Laparoscopic radical hysterectomy and total vaginectomy for vaginal malignant melanoma with cervical metastasis

The presented case is a 63-years-old multiparous woman admitted with the complaint of postmenopausal bleeding. On gynecologic examination multifocal lesions were detected, including 1 cm on lateral vaginal wall, 4 cm on posterior vaginal wall and 0.5 cm on the left lateral part of the cervix. Histopathology examination gave a diagnosis of epithelioid malignant melanoma. Consequently, laparoscopic radical hysterectomy and total vaginectomy with bilateral pelvic and inguinofemoral lymph node dissection were planned. On both sides, pararectal and paravesical spaces were created and the ureter was identified. Then, the vesicouterine and vesicovaginal spaces were developed. Uterine artery and superior vesical artery were coagulated, cut and the lateral parametrium was prepared. The left ureter was dissected and the ureteral tunnel was unroofed up to the bladder entrance. Subsequently, the anterolateral parametrium was transected. Then, the infundibulopelvic and sacrouterine ligaments were sealed and transected. At this time, the rectovaginal space was developed. Bilateral paracolpos were transected. The endopelvic fascia with the levator muscles were sealed and cut circumferentially. Anteriorly, the pubovesicocervical fascia was transected and the bladder was mobilized up to the uretrovesical junction. Thereafter, through a vaginal approach, the cervix and vagina were inverted by grasping the cervix with a tenaculum. An incision on the posterior vaginal wall at the introitus was made and the urogenital diaphragm was dissected to connect with the pelvic cavity. The vaginal entrance was cut circumferentially and the surgical specimen was extracted. In conclusion, laparoscopy can be considered as a feasible approach for radical hysterectomy and total vaginectomy in selected patients.

The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse.

Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament. We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures. We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture. Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

Vaginal colpotomy approach for ovarian cystectomy for a mature cystic teratoma

Vaginal colpotomy approach for ovarian cystectomy for a mature cystic teratoma

The influence of obesity on surgical outcomes of vaginal natural orifice transluminal endoscopic surgery approach

The influence of obesity on surgical outcomes of vaginal natural orifice transluminal endoscopic surgery approach