Vaginal Approach Research Articles

Minimally invasive vaginal approach to the uterovestibular anastomosis for cervicovaginal aplasia: a case series and review of literature.

Congenital cervicovaginal agenesis (CVA) with functioning endometrium is an extremely rare mullerian anomaly. Genital tract patency and fertility preservation are the major challenges in cases of CVA. With the advances in surgical techniques, management has shifted from a radical approach-like hysterectomy towards a more conservative approach of uterine conservation. In the present study, we report our experience in managing four cases of congenital CVA with complete vaginal atresia, which were treated with a simple minimally invasive vaginal approach for UVA without using graft for neovagina creation and studied the long-term anatomic and functional result of uterovestibular anastomosis (UVA) in patients with CVA. A literature review was performed for congenital complete vaginal atresia (≤ 2cm blind vagina), with a functioning uterus. The experience and results of this 4-year study are in accordance with the prior studies with 97% (33/34) success rate, where vestibular mucosa was used for the UVA. Findings of this study should encourage more gynaecologists to learn and recreate a complete vaginal approach, as no special surgical equipments are needed. Hysterectomy should only be reserved for cases, where repeated anastomosis attempts fail. This minimally invasive technique should be preferred over canalization procedures and graft, as it is associated with a higher success rate with least complications and recurrence. Conservative end-to-end anastomosis with a completely vaginal approach should be offered as the primary treatment option for CVA with total vaginal atresia.

Unilateral pectineal suspension - A new surgical approach for apical correction of pelvic organ prolapse.

There are numerous vaginal and abdominal surgical approaches for the treatment of pelvic organ prolapse (POP). Even the standard techniques show great variability due to modifications depending on anatomy, available instruments and materials. Recently, the role of hysterectomy in prolapse surgery as well as the use of synthetic meshes have been questioned. Here, we present a standardised mesh-free minimally invasive pelvic floor reconstruction technique with uterus preservation. Unilateral pectineal suspension (UPS) is carried out in five defined steps with the use of the da Vinci Xi ® surgical system. The desired anatomical result is simulated by intraoperative uterus manipulation. The cranial part of the pectineal ligament is used for lateral fixation. A non-absorbable suture is placed between the pectineal ligament and the anterior cervix to suspend the uterus in its natural anatomical position. For outcome measurement, degree of prolapse was assessed pre- and postoperatively according to the POP-Q system. Unilateral pectineal suspension offers several advantages. Medial tension-free positioning of the uterus is achieved. The use of the cervix as fixation structure allows for excellent pelvic floor support and stable results. Normal pelvic floor mobility and natural axis of the vagina are restored. Unilateral pectineal suspension is an efficient minimal-invasive mesh-free procedure which allows uterus preservation and offers reliable level I support respecting the physiological pelvic anatomy. In addition, there is no need for ureteral dissection or bowel manipulation. The technique offers clinical standardization and can easily be integrated into the spectrum of modern surgical POP repair.

Robotic vaginal natural orifice transluminal endoscopic myomectomy

Robotic vaginal natural orifice transluminal endoscopic myomectomy

Comparison between anterior and posterior vaginal approach in apical prolapse repair in relation to anatomical structures and points of fixation to the sacrospinous ligament in fresh postmenopausal female cadavers.

The high prevalence of pelvic organ prolapse (POP) in women requires attention and constant review of treatment options. Sacrospinous ligament fixation (SSLF) for apical prolapse has benefits, high efficacy, and low cost. Our objective is to compare anterior and posterior vaginal approach in SSLF in relation to anatomical structures and to correlate them with body mass index (BMI). Sacrospinous ligament fixation was performed in fresh female cadavers via anterior and posterior vaginal approaches, using the CAPIO®SLIM device (Boston Scientific, Natick, MA, USA). The distances from the point of fixation to the pudendal artery, pudendal nerve, and inferior gluteal artery were measured. We evaluated 11 cadavers with a mean age of 70.1 ± 9.9 years and mean BMI 22.4 ± 4.6 kg/m2. The mean distance from the posterior SSLF to the ischial spine, pudendal artery, pudendal nerve, and inferior gluteal artery were 21.18 ± 2.22 mm, 17.9 ± 7.3 mm, 19.2 ± 6.8 mm, and 18.9 ± 6.9 mm respectively. The same measurements relative to the anterior SSLF were 19.7 ± 2.7 mm, 18.6 ± 6.7 mm, 19.2 ± 6.9 mm, and 18.3 ± 6.7 mm. Statistical analysis showed no difference between the distances in the two approaches. The distances from the fixation point to the pudendal artery and nerve were directly proportional to the BMI. There was no difference in the measurements obtained in the anterior and posterior vaginal approaches. A direct correlation between BMI and the distances to the pudendal artery and pudendal nerve was found.

Individualized Assessment of Risk of Complications after Benign Hysterectomy

The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. Retrospective cohort. The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Prevalence and outcome of hysterectomy in a peripheral medical college – A data-based retrospective study

Aims and Objectives: The study aimed evaluation of prevalence, demographic features, clinical presentation, indication, intra-operative findings, different types of operation, and histopathological diagnosis of patients who underwent hysterectomy in our center. Materials and Methods: This retrospective study done over 3 years from May 2017 to April 2020 in Department of Obstetrics and Gynecology of Rampurhat Government Medical College, West Bengal India. Case record and data of each patient were obtained from medical record section of the hospital and analyzed after taking permission of concerned authority. Inclusion criteria: Those underwent hysterectomy for gynecological indications during our study periods. Results: During the study period, total 6014 obstetrical and gynecological surgery performed; out of them, 424 cases of hysterectomies were studied, maximum patients (64.85 %) underwent hysterectomy at the age group of 41–50 years. Menorrhagia was the most common (61.32%) presenting complains. Leiomyoma was the most common (27.12%) indication followed by abnormal uterine bleeding (22.17%) and pelvic organ prolapses (11.57%). Maximum (79.25%) with abdominal route and 20.75% cases through vaginal approach. Total abdominal hysterectomy with bilateral salpingo-ophorecctomy 270 cases (63.69%), vaginal hysterectomy with pelvic floor repair 60 (14.15%), total abdominal hysterectomy without oophorectomy 50 (11.79%), and radical hysterectomy 16(3.77%).Dominant histopathological type was leiomyoma (22.88%). Among various post-operative complications, urinary tract infection was the most common (9.19%), the most of the postoperative complication was found in abdominal hysterectomy. Conclusion: For treating pelvic pathologies such as uterine bleeding, adenomyosis, fibroid, pelvic inflammatory disease, malignant disorder, and genital prolapse hysterectomy is preferred procedure and abdominal route was most common. Complication of vaginal hysterectomy is less than abdominal approach. Vaginal approach should be preferable approach.

TRANSVAGINAL REPAIR OF VESICOVAGINAL FISTULA: EXPERIENCE AT A TERTIARY CARE CENTRE.

Aim: to highlight the transvaginal route as an effective approach for repair of simple vesico-vaginal and urethro-vaginal stulae without compromising patient outcomes. Materials and Methods: A retrospective analysis was carried out on 45 patients with simple trigonal, supra trigonal and urethrovaginal stula who underwent transvaginal repair in the last 3 years. Simple stulas were dened as stula less than 3 cm in size or recurrent stulae less than 1.5–2 cm in size and located either supra-trigonally (above the bar of mercier) or sub-trigonally (below the bar of mercier) as determined by cystoscopy. Results: Obstetric cause, due to obstructed labour, was the most common cause of stula formation (68.96%), while remaining (29.31%) were attributed to hysterectomy. Primary stulae were found in 68.9% of patients and recurrent stulae in 31.1% patients. The mean age of patients was 34.30 years. Average stula size was 1.5 cm. The success rate of primary operation was 84.12%. On using a multivariate regression model, the underlying aetiology (OR 2.2), stula location (OR 2.5) and history of previous repair (OR 2.4) were found to be signicant factors affecting outcome. Conclusion: The transvaginal approach is less invasive and achieved comparable success rates as compared to other methods of vesico-vaginal stula repair. We postulate that vaginal approach should be preferred over abdominal approach for repair of all vaginally accessible vesico vaginal stulae, both of obstetrical and gynaecological origin.

Outcomes of the anterior approach versus posterior sacrospinous ligament fixation for pelvic organ prolapse.

This study aimed to compare anterior sacrospinous ligament fixation (SSLF) with the standard posterior SSLF concerning complications and outcomes in patients with apical compartment pelvic organ prolapse (POP). This is an observational descriptive study using prospective data collected from two referral urogynecological centers. The study cohort represents all 135 women in our prospective study who underwent anterior approach bilateral anterior or unilateral posterior meshless SSLF from January 2018 to December 2020 using the PFDI-20 questionnaire and the POP quantification (POP-Q) system pre- and postoperatively. The objective success rate was assessed by the number of POP recurrence cases and total vaginal length (TVL) postoperatively. Patients were followed up for at least 6 months (range, 6 to 18 months). Data were analyzed using SPSS version 21. P < 0.05 was considered statistically significant. Sixty-seven (49.6%) patients underwent posterior SSLF, and 68 (50.4%) underwent anterior SSLF. The mean age of patients was 58.2 ± 9.7 and 64.9 ± 11.6, respectively (P < 0.001). Most patients who underwent the posterior approach had stage III apical prolapse (74.6%), while 65.5% of those who underwent anterior SSLF had stage II apical prolapse (P < 0.001). Following the treatment, no significant difference was detected between these two vaginal approaches in terms of women's satisfaction rate (P > 0.05). One case of postoperative recurrence was found in the posterior group, which ultimately led to surgical retreatment. There were no major intra- or postoperative complications in the groups. Postoperative TVL was higher in the anterior SSLF group (P < 0.001). The postoperative POPDI-6, CRADI-8, UDI-6, and PFDI-20 decreased significantly compared to preoperative status in both groups (P < 0.001). It appears that the anterior SSLF approach can be regarded as effective as the posterior approach in the management of apical POP. Therefore, the proper surgical technique can be chosen according to the surgeon's expertise and other compartment's prolapse status.

Geographic Variation in Apical Support Procedures for Pelvic Organ Prolapse.

To measure geographic variation in rates of apical support procedures for the treatment of pelvic organ prolapse (POP) among female Medicare beneficiaries. We conducted a retrospective, cross-sectional study and used 100% Medicare fee-for-service claims to identify a cohort of women aged 65-99 years who had an apical support procedure, defined by Current Procedural Terminology codes, in 2016-2018. We included all vaginal and abdominal approaches (native tissue and mesh colpopexies) and obliterative procedures. We excluded vaginectomies with a diagnosis of gynecologic cancer that did not have a diagnosis for prolapse. We created rates of apical POP procedures by hospital referral region and computed coefficients of variation to measure the degree of geographic variation. An average of 26,005 apical POP procedures were performed annually from 2016 to 2018. The majority of patients were aged 65-74 years (64.3%), and 28.5% had concomitant hysterectomy. From 2016 to 2018, there was a mean of 1.79 apical POP procedures per 1,000 female beneficiaries performed across hospital referral regions (95% CI 1.74-1.84). Rate estimates ranged between 0.87 (95% CI 0.63-1.11) apical POP procedures per 1,000 female beneficiaries (Alexandria, Louisiana) and 3.33 (95% CI 2.91-3.74) per 1,000 beneficiaries (Akron, Ohio), a nearly fourfold difference in rates. Variation between hospital referral regions for abdominal apical prolapse procedures was the greatest (coefficient of variation 0.52). Vaginal and obliterative approaches demonstrated less variation between hospital referral regions (respectively, coefficient of variation 0.36 and 0.40). There is wide geographic variation among hospital referral regions for the treatment of POP. Women may be treated differently based on where they live and seek care, which raises questions about possible overuse in some regions and concerns about underuse and lack of access in other regions.

36 Feasibility and safety of short stay hysterectomy

Introduction: The proportion of laparoscopic hysterectomies (LH) in the United Kingdom and United States have increased significantly compared to abdominal or vaginal approaches. These endoscopic techniques combined with advances in technology and training have enabled shorter lengths of stay after gynaecological surgery, with 13.3% of hysterectomies performed as an ‘outpatient’ (‘day-case’ or ‘ambulatory’) procedure in the US in 2008 vs. 57.5% in 2014. Objective: The aim of this study was to evaluate the safety and identify factors associated with feasibility of short-stay following laparoscopic hysterectomy.

Short-Term Urinary Retention After Tension-Free Vaginal Tape Midurethral Sling Performed Alone or as a Concomitant Procedure.

The objective was to determine whether a difference exists in short-term urinary retention after tension-free vaginal tape (TVT) midurethral sling placement when performed alone compared with when placed during a concomitant prolapse procedure. We conducted a single-center retrospective cohort study that compared TVT procedures performed alone (group 1) to those with a concomitant prolapse procedure (group 2). The primary outcome was the proportion of patients discharged with an indwelling Foley catheter after failing postoperative voiding trial. There were 100 women in group 1 and 267 women in group 2. Concomitant prolapse procedures included vaginal approach (n = 47), robotic (n = 218), or both (n = 2). Forty-nine patients (13.4%) failed the initial voiding trial and 21 patients (5.7%) were discharged with an indwelling Foley catheter. The rate of short-term urinary retention requiring an indwelling catheter at discharge was not significantly different between group 1 and group 2 (9 [9.0%] vs 12 [4.5%], P = 0.1). The duration of catheterization after discharge was shorter in group 1 compared with group 2 (2.1 ± 1.1 vs 4.3 ± 2.0 days, P = 0.008). In multivariate analysis, patients discharged with a catheter were more likely to have diabetes with an odds ratio of 3.1 (95th confidence interval, 1.2-8.1). The proportion of patients discharged with an indwelling catheter did not significantly differ if TVT was performed alone or at the time of a concomitant prolapse procedure (9.0% vs 4.5%, P = 0.1).

Multidisciplinary minimally-invasive approach to complex vesicovaginal fistula repair

This video's objectives are to demonstrate the techniques and decision process used in the approach to a complex vesicovaginal fistula resulting from obstetric injury, after previous attempts at repair had failed. Our patient was referred from an outside institution to us. At emergent cesarean delivery at 24 weeks, hemoperitoneum, uterine rupture, and placenta percreta were found. During hysterectomy, the right ureter was ligated and the posterior wall of the bladder sustained large cystotomies. Urology repaired the injury, reimplanted the ureter, and placed a right ureteral stent, but the patient developed a vesicovaginal fistula and left ureteral obstruction. Ten months after diagnosis, it was repaired using a robot-assisted laparoscopic approach. This required bilateral ureteral re-implantation and omental flap. Unfortunately, this repair broke down, and testing was concerning for vesicovaginal and left ureterovaginal fistula, high at the vaginal apex. The patient was referred to our institution for our attending surgeon's expertise in fistula repair. Takeaways from this video presentation include: careful delineation of genito-urinary anatomy, vaginal approach, optimization of visualization, wide mobilization of tissue around the defect, watertight closre, meticulous multilayer closure, and aggressive management of infection.

Vnotes: a vaginal approach to laparoscopic hysterectomy and prolapse repair

The objective of this video is to describe the set-up, execution, and advantages of laparoscopy via a vaginal approach for hysterectomy and pelvic organ prolapse repair. This video details the case of a 63-year-old patient with stage II symptomatic pelvic organ prolapse and mixed urinary incontinence. She had a history of prior pelvic surgery including a sigmoid colectomy and reanastomosis and strongly desired hysterectomy and bilateral salpingo-oophorectomy at the time of her prolapse repair. Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy (BSO), and uterosacral ligament vaginal vault suspension were performed via the vNOTES procedure. Technique, equipment, set-up, and strategies for success are described throughout the video. Pelvic anatomy from a vaginal vantage point is highlighted and a direct view during crucial points of each procedure is provided. Laparoscopic techniques including lysis of adhesions and retroperitoneal exploration are detailed in the video as a result of her prior surgery. This video demonstrates the equipment and feasibility of vaginal laparoscopy and highlights the advantages of increased visualization during difficult vaginal surgery.

Historical and forecasted changes in utilization of same day discharge following minimally invasive hysterectomy

To describe changes in same day discharges (SDD) following minimally invasive hysterectomy (MIH) in a national surgical database across a 9-year period and forecast anticipated utilization over the subsequent decade. A cross-sectional secondary analysis of the 2011-2019 National Surgical Quality Improvement Program (NSQIP) Database combined with an autoregressive linear forecasting model of SDD utilization from 2020-2029. MIH were identified by current procedural terminology (CPT) code and indication for surgery based on primary diagnosis ICD-CM coding. Individuals with an oncologic diagnosis or concomitant non-gynecologic procedure were excluded. Multivariable logistic regression was used to control for individual-level confounding factors. 239,242 MIH were included in the analysis. Over the 9-year period, there was a sustained increased utilization of SDD across all MIH (13.0% in 2011 to 23.7% in 2019; Cochran Armitage test for trend P<0.001). Surgery for a diagnosis of pelvic organ prolapse was associated with a 15.8% lower rate of SDD compared to those with another benign indication (P<0.001) and this gap increased across time (P<0.001) (Figure 1). Moreover, the observed differences persisted when controlling for individual confounders including age, ASA classification, BMI, functional status, presence of major medical comorbidities, and route of hysterectomy (aOR for prolapse 0.40 (95% CI 0.38, 0.42)). Route of hysterectomy also affected SDD rate, with total laparoscopic hysterectomy having the highest rate of SDD (28.3%) while total vaginal hysterectomy was associated with the lowest (12.0%) (aOR for vaginal hysterectomy 0.47 (95% CI 0.45, 0.48). Based on the demonstrated trends, forecasting models estimate overall utilization of SDD will increase to 48.5% (95% CI 38.7-58.4) by 2029 (Figure 2). While utilization is increasing, the overall rate of SDD following MIH remains low, particularly among individuals undergoing surgery for pelvic organ prolapse and by a vaginal approach. Given its well established safety profile, additional strategies to facilitate SDD of patients undergoing MIH should be adopted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Radical Hysterectomy After the LACC Trial: Back to Radical Vaginal Surgery

Classical radical vaginal hysterectomy first performed by Anton Pawlik in Prague in 1888 and popularized by Frederic Schauta is now a historical technique virtually abandoned due to painful perineal incision, a high rate of urinary dysfunction, and the inability to perform lymph node assessment. However, the heritage of this approach has been still used and taught in a few centers outside their Austrian birthplace. A combined vaginal and laparoscopic approach was developed in the 1990s by French and German surgeons who designed diverse surgical techniques for which a novel classification is proposed. All these techniques are different from the so-called laparoscopically assisted radical vaginal hysterectomy (LARVH), a term widely used for laparoscopic radical hysterectomies with vaginal extraction of the specimen. Interestingly, after the publication of the LACC trial (Laparoscopic Approach to Cervical Cancer), the radical vaginal approach has found a very timely application. The creation of a vaginal cuff before performing radical laparoscopic hysterectomy described in 2007 by Leblanc as "Schautheim" operation can be used as a protective maneuver to avoid tumor spillage and potentially overturn the negative outcome of minimally invasive surgery in early-stage cervical cancer. As a result, the combination of radical vaginal and laparoscopic steps of surgery is one possible evolution after the LACC trial that needs further investigation. The forgotten vaginal surgical technique needs a specific learning curve. The creation of a vaginal cuff should be mastered by every gynecological oncologist.

Stérilisation tubaire par voie vaginale : à propos d’une série de 158 patientes de 2005 à 2021

ObjectivesThe latest recommendations of 2006 on tubal sterilization reported an infectious risk of 1.5 to 2.5% for the vaginal approach. There is, however, limited literature on this approach. The primary objective of our study was to investigate the feasibility of tubal sterilization via posterior colpotomy. The secondary objectives were to study the reproducibility of this approach, the postoperative infection rate after tubal sterilization via posterior colpotomy, to evaluate its peroperative and postoperative morbidity. MethodsThis retrospective study, conducted at the Antibes's Hospital, included patients over 18 years of age who underwent tubal ligation with clips or bilateral vaginal salpingectomy from 2005 to 2021. ResultsWe included a total of 158 patients: 88% by clips and 12% by bilateral salpingectomy. The average operative duration was of 27 minutes. There were no infectious or postoperative complications directly related to the sterilization. There were two failures of the technique, requiring conversion to laparoscopy (1.3%) and four subsequent pregnancies (2.5%). ConclusionsWe were able to show low morbidity and failure rates with this surgical technique. It, therefore, does not appear to be inferior to the laparoscopic approach. Moreover, it is reproducible technique.

Feasibility of Fetal Portal Venous System Ultrasound Assessment at the FT Anomaly Scan.

Objective: To investigate the feasibility of the first trimester (FT) ultrasound scan (US) for the evaluation of the fetal portal venous system (PVS) anatomy, and to evaluate the potential of microcopy for a proper pathology evaluation for the PVS in the FT. Methods: We evaluated the PVS in 200 scan examinations performed in FT pregnancy. Half of the cases were scanned by two operators with extensive experience in obstetric ultrasound—Group I, and the other half was evaluated by two sonographers with less experience—Group II. Second-trimester US and autopsy in terminated pregnancies were used as follow-up. The pathologic evaluation was supported by microscopy. Results: all PVS features were successfully assessed by transabdominal ultrasound (TAUS) in 27% of the Group I cases and 14% in Group II. These rates increased to 88% in Group I and in 72% in Group II, after rescanning and using transvaginal ultrasound (TVUS). The conditions that led to rescanning and TVUS were: BMI greater than 24 in 26% cases, unfavorable fetal position (12.32%), retroverted uterus (12.32%), abdominal scar (10.96%), fibroids (4.11%), and combinations of the above (34.23%). The L-shaped UV confluence was identified transabdominally in 91% in Group I and in 79% in Group II and increased to 98% and 95%, respectively, following reevaluations. Microscopy represented a useful audit in all FT investigated cases. Conclusions: At the end of the FT, the visualization of a normal L-shaped UV confluence, that excludes major PVS abnormalities, is achievable in approx. 80%, indifferently the examiners experience. The sonographers experience, pregnant women BMI, and uterine anomalies as fibroids or retroversion significantly affect the rate of visualization, and necessitates vaginal approach and reexamination. The FT pathology, the audit of the ultrasound findings can only be performed microscopically, with relatively little resources involved and good results.

Transvaginal Approach for Repair of Vesico Vaginal Fistula: An Effective Approach

To describe that the transvaginal approach is an excellent route for the repair of vesico vaginal fistula without compromising on success rate. Material and Method: It is a reterospective analysis of 64 cases operated in 10 years. All were operated through transvaginal approach. Study included all supratrigonal, trigonal and infratrigonal fistulas as classified on cystoscopic findings bases. Results: Sixty four patients with vesico vaginal fistula were included in the study. The age of patients was from 20 to 58 years with a mean age of 44.6 years. According to age these were divided into four groups. The cause of vesico vaginal fistula was abdominal hystrectomy in 57 (89.06%) patients while obstructive labour in 7 (10.96%) patients. The size of fistula was further categorized in three groups. The success rate was 87.5% (56 patients) in first attempt while the fistula of remaining 8 patients (12.5%) was successfully repaired in second attempt. Supra trigonal fistula was present in 54 (84.38%) patients while 10 (15.62%) patients had trigonal or infra trigonal fistula. Conclusion: By comparing different approaches, the vaginal approach had a comparable success rate with less morbidity. We suggest, for repair of vesico vaginal fistula, the transvaginal approach should be a preferred approach for a vaginally accessible fistula over tranabdominal approach.

Perioperative use of pain medications in vaginal versus laparoscopic pelvic organ prolapse surgery.

There has been renewed interest in the management of postoperative pain after benign gynecological surgery. The purpose of the study was to determine if the use of intraoperative and immediate postoperative pain medication differs between vaginal and laparoscopic surgery in women with pelvic organ prolapse. The study included women who had undergone pelvic organ prolapse repair between 2014 and 2019 in two tertiary care hospitals. We collected demographic data and pain medication used during and after surgery, including opioids, local anesthetics, gabapentin, ketorolac, ibuprofen, and acetaminophen. Data analyses were performed using STATA Version 16.1. A p value <0.05 was considered to indicate statistical significance. A total of 195 women were included in the study, with 98 in the vaginal and 97 in the laparoscopic group. Intraoperative opioid use in the two groups was similar (25 morphine milligram equivalent [MME], p = 0.34). However, women in the laparoscopic group received significantly more intravenous and local anesthesia (lidocaine: 60 vs 40mg; bupivacaine 49.6 vs 20ml, p < 0.001). Postoperatively, although women in the vaginal group required almost twice as many narcotics as those in the laparoscopy group (MME = 28 vs 15, p < 0.001), after controlling for confounders in the multivariate analysis, there were no differences in postoperative pain requirements between the two groups. Recovery time had a significant impact on opioid and acetaminophen use (p < 0.05). Use of pain medication was similar in the intraoperative and immediate postoperative period after pelvic organ prolapse surgery when comparing the vaginal and laparoscopic approaches after controlling for potential confounding factors.

Urethral Exposure of Mid-urethral Sling: Diagnosis, Management and Functional Outcomes

ObjectiveTo identify symptoms leading to urethral mesh exposure diagnosis, describe the surgical management and evaluate post-operative functional and urodynamic outcomes. Materials and MethodsRetrospective observational monocentric study of 15 patients treated by mid-urethral sling removal for urethral exposure, between December 2005 and February 2021, in a pelviperineology centre. ResultsFifteen patients were included. The mean time to diagnosis of urethral exposure was 43 months. This diagnosis delay was caused by a non-specific symptomatology. Surgical management consisted of partial removal of the eroded mid-urethral sling fragment by vaginal approach in all cases, with low peri-operative morbidity. At 3 months follow-up, 87% of the patients had stress urinary incontinence vs 54% at 2 years. 13 patients had a urodynamic assessment after their mid-urethral sling removal, they all had sphincter insufficiency with a urethral closure pressure lower than 30 cm H2O. Nine patients underwent a second urinary incontinence management procedure, leading to 77% of complete remission and 23% of partial improvement. ConclusionClinical presentation of urethral erosion after mid-urethral sling is heterogeneous. Surgical management is complex; after a good preoperative evaluation, a two-step management strategy including minimally invasive mid-urethral sling removal and treatment of recurrent urinary incontinence leads to good results with 77% of patients cured. Sphincter insufficiency is one of the mechanisms that may explain the high rate of stress urinary incontinence after urethral mesh erosion surgery.