Vaginal Dehiscence Research Articles

Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset.

Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after radical cystectomy (RC) in female patients with invasive bladder cancer, However, it often requires emergency surgical repair. Here, we describe our experience with such a case and a review of similar previously reported cases, along with evaluation of the risk factors. We also propose a vaginal reconstruction technique to prevent this complication during robot-assisted laparoscopic radical cystectomy (RARC). A total of 178 patients who underwent laparoscopic radical cystectomy (LRC) or RARC were enrolled, 34 of whom (19%) were female. One of the 34 female patients had transvaginal small bowel evisceration after RARC. We evaluated our case and six such previously reported cases, to determine vaginal reconstruction techniques during RARC to prevent this complication postoperatively. Median age of these cases was 73 (51-80) years, and all patients were postmenopausal. The median time to small bowel evisceration was 14 (6-120) weeks postoperatively. In addition, we changed the methods of the vaginal reconstruction technique during RARC from the conventional side-to-side closure technique to the improved caudal-to-cephalad closure technique. Since implementing this change, we have not experienced any cases of vaginal vault dehiscence or organ prolapse. Transvaginal small bowel evisceration after RC can easily become severe. Therefore, all possible preventive measures should be taken during RARC. We believe that our vaginal reconstruction techniques might reduce the risk of developing this complication.

Combined Robotic and Vaginal Surgery for Pelvic Exenteration Due to Vaginal Sarcoma Relapse in an Obese Woman

Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed. The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM). Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling. The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m2), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up. Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.

Repair of Vaginal Cuff Dehiscence after Laparoscopic Radical Cystectomy with Gracilis Myocutaneous Flap

Vaginal cuff dehiscence after total hysterectomy or total cystectomy had been increasing since laparoscopic or robotic surgery became a common surgery among gynecologists and urologists. A 52-yearold woman underwent laparoscopic radical total cystectomy for muscle invasive bladder carcinoma at Rakuwakai Otowa Hospital. She was emergently admitted with a fist-sized lump protruding from her vagina four months after surgery. Physical examination and her past history on admission disclosed vaginal cuff dehiscence after cystectomy. Computed tomographic scan and magnetic resonance imaging showed no bowel evisceration in the lump. We confirmed that the content of lump was peritoneal tissue and removed it by laparoscopic surgery. Simultaneously, we repaired the vaginal cuff dehiscence with a gracilis myocutaneous flap. There was no subsequent recurrence of vaginal dehiscence or bladder carcinoma in one-year follow-up.

Laparoscopic Modified Radical Hysterectomy for Severe Endometriosis: A Single-Center Case Series

Study objectiveThe main objective is to describe the feasibility and report a single centre experience of a standardized laparoscopic modified radical hysterectomy technique among patients with severe endometriosis and pouch of Douglas obliteration. DesignA single-center case series of laparoscopic modified radical hysterectomy performed at the Poissy Hospital between December 2012 and May 2021. SettingsSingle-center, gynecology unit (level III) with a focus on endometriosis. PatientsPatients with severe endometriosis (stage 4 AFS) and pouch of Douglas Obliteration. Measurements and Main ResultsFifty-two patients with severe endometriosis underwent the surgical procedure.Out of these patients: 23.1% underwent a rectal shaving (n= 12), 1.9 % a discoid resection (n= 1) and 17.3% a rectal resection (n= 9), including a protective ileostomy in one case. Ureterolysis was performed on 82.7% of patients (n= 43). The average hospital stay was 3.3 days (1-12). Seven patients required intermittent self-catheterization (13.5%). Minor complications (Clavien-Dindo grade 1 and 2) occurred to 25.9% of the patients and severe complications to 3.8% of them (Clavien-Dindo grade 3, no grade 4). Two patients (3.8%) were reoperated: one for a postoperative occipital alopecia (balding) and the other for vaginal dehiscence with evisceration. About 50 patients (96.2%) had a complete resection of endometriosis. The median follow-up was 14 months (interquartile range 6-23 months) with 94.3% of them improved (much and very much) and 3.8% minimally improved. ConclusionIn our experience, laparoscopic modified radical hysterectomy is a reliable procedure with a low rate of severe complications. This technique needs to be assessed by other surgeons and others centers across the country and abroad, in order to determine the likehood of it succeeding.

MP07-12 PELVIC FLOOR SUPPORT FOLLOWING FEMALE RADICAL CYSTECTOMY: A LONGITUDINAL OBSERVATIONAL STUDY

You have accessJournal of UrologyCME1 Apr 2023MP07-12 PELVIC FLOOR SUPPORT FOLLOWING FEMALE RADICAL CYSTECTOMY: A LONGITUDINAL OBSERVATIONAL STUDY Shree Agrawal-Patel, Sandip Vasavada, David Rapp, Sarah Martin, Lauren Gleich, Tracey Krupski, Byron Lee, and Jacqueline Zillioux Shree Agrawal-PatelShree Agrawal-Patel More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , David RappDavid Rapp More articles by this author , Sarah MartinSarah Martin More articles by this author , Lauren GleichLauren Gleich More articles by this author , Tracey KrupskiTracey Krupski More articles by this author , Byron LeeByron Lee More articles by this author , and Jacqueline ZilliouxJacqueline Zillioux More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Women are at risk of pelvic organ prolapse and sexual dysfunction following radical cystectomy (RC); however, these outcomes are under-appreciated and understudied. We aimed to assess the natural history of pelvic floor support and vaginal symptoms following female RC. METHODS: This is an interim analysis of an IRB-approved multicenter prospective observational study of pelvic floor support in women undergoing RC from 3/2021 to 5/2022. All women undergoing RC at 2 institutions were recruited. Participants underwent pelvic exam including Pelvic Organ Prolapse Quantification System (POP-Q) measurements by an FPMRS-trained urologist at baseline and routine postoperative visits. Participants completed validated questionnaires (Pelvic Floor Disability Index (PFDI-20); International Consultation on Incontinence Questionnaire Vaginal Symptoms (ICIQ-VS)) at each visit. Surgical details including amount of vaginal tissue removed during non-vaginal-sparing RC were recorded. RESULTS: Fourteen women enrolled and had at least one postoperative visit through 6-months. Median age was 69 years. Approach was robotic in n=9 (64%) and vaginal-sparing in n=5 (38%). Indication was benign for 3 patients and all underwent non-orthotopic diversion. One vaginal-sparing benign case had concomitant mesh sacrocolpopexy for baseline stage 3 apical prolapse, while one patient from sparing and non-sparing groups had concurrent uterosacral ligament plication. All non-vaginal-sparing cases had clamshell reconstruction following excision of a median of 4.0 [4.0, 6.0] cm length and 2.5 [2.0, 4.0] cm width vaginal tissue, representing median 48% of baseline total vaginal length removed. Table 1 illustrates longitudinal POP-Q exam and questionnaire scores of vaginal sparing and non-sparing cases. One patient had anterior vaginal wall dehiscence requiring debridement under anesthesia but ultimately not reconstruction. CONCLUSIONS: To our knowledge, this is the first prospective study of pelvic floor support following female RC. Though further study is needed, preliminary findings through 6-month follow-up suggest vaginal foreshortening in both vaginal-sparing and non-sparing cases. Both groups appear to have mild anterior/posterior prolapse progression, although without worsened symptom scores. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e89 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shree Agrawal-Patel More articles by this author Sandip Vasavada More articles by this author David Rapp More articles by this author Sarah Martin More articles by this author Lauren Gleich More articles by this author Tracey Krupski More articles by this author Byron Lee More articles by this author Jacqueline Zillioux More articles by this author Expand All Advertisement PDF downloadLoading ...

Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy

BackgroundThe use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis.MethodsWe reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others.ResultsIn the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate.ConclusionsThe effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.

Vaginal Cuff Dehiscence Rates by Mode of Hysterectomy: An Update

<h3>Study Objective</h3> To report vaginal cuff dehiscence rates by mode of hysterectomy as the surgical landscape has shifted towards minimally invasive approaches. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Large academic medical center and affiliated community hospital. <h3>Patients or Participants</h3> 4722 patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. <h3>Interventions</h3> Hysterectomy patients and vaginal cuff dehiscences were identified by ICD and CPT codes. <h3>Measurements and Main Results</h3> There were 663 supracervical hysterectomies and 4059 total hysterectomies identified (1360 robot-assisted total laparoscopic hysterectomies [RA-TLH, 28.8%], 1107 total abdominal hysterectomies [TAH, 23.4%], 938 total laparoscopic hysterectomies [TLH, 19.9%], 498 total vaginal hysterectomies [TVH, 10.5%], and 156 laparoscopic-assisted vaginal hysterectomies [LAVH, 3.3%]). Supracervical hysterectomies were excluded from analysis. Among 4059 total hysterectomies, there were 15 vaginal dehiscences (0.37%). The dehiscence rate was highest after RA-TLH at 0.66% (n=9), followed by TLH at 0.32% (n=3), and TAH at 0.27% (n=3), with no dehiscences after TVH or LAVH; these differences were not statistically significant (<i>p</i>=0.31). Compared to TAH, the relative risk for dehiscence after RA-TLH was 2.44 (95% CI 0.66 – 9.00), and after TLH was 1.18 (95% CI 0.24 – 5.83), which were also not statistically significant. Patient characteristics were reviewed including age, hysterectomy indication, colpotomy type, suture type, medical comorbidities, and presentation. The mean time to dehiscence was 39 days (range 8 – 145). The most common trigger event was coitus (41%). Most dehiscences followed benign hysterectomies (88%). <h3>Conclusion</h3> Our study offers the largest representation of robotic hysterectomies to date. Although dehiscence rates were higher after laparoscopic hysterectomy (RA-TLH 0.66%, TLH 0.32%) compared to abdominal hysterectomy (TAH 0.27%), the differences were not significant. Our 0.66% RA-TLH dehiscence rate is much lower than previously reported in large studies (1.6 – 4.1%). While broad conclusions are limited, dehiscences are overall rare (0.37%). More research is needed to evaluate factors responsible for increased risk.

Adjuvant hysterectomy following primary chemoradiation for stage IB2 and IIA2 cervical cancer: a retrospective comparison of complications for open versus minimally invasive surgery

BackgroundAdjuvant hysterectomy following chemoradiation for bulky, early stage cervical cancer has been shown to decrease local relapse rate. The objective of this study is to compare complications and recurrences between minimally invasive and open adjuvant hysterectomy for early stage cervical cancer.MethodsPatients were identified who had undergone adjuvant hysterectomy following chemoradiation for 2009 FIGO stage IB2 and IIA2 cervical cancer from August 2006 to June 2018. Demographic information, treatment course, complications, recurrence data were retrospectively extracted from the medical record. Frequency of complications was compared with Fisher exact test or chi-square test as appropriate and inverse probability of treatment propensity score weighting was used to calculate the disease-free survival.ResultsFifty-four patients met inclusion criteria with a median follow up time of 60.4 months (interquartile range 28.0–98.1 months). There were 24 (44%) open versus 30 (56%) minimally invasive hysterectomies performed. The overall grade 2 or worse complication rate was 43%. There were 8 (27%) patients with complications in the minimally invasive group compared to 4 (17%) in the open group (OR 1.82 (95% CI 0.5–7.0)). There were 9 vaginal cuff defects, dehiscences and/or fistulas in the minimally invasive group compared to 3 in the open group (OR 3.0 (95% CI 0.8–11.2)). There was no statistically significant difference between disease free survival and overall survival among the two groups, however there was a trend towards decreased disease-free survival in the minimally invasive group.ConclusionsAmong women undergoing adjuvant hysterectomy following chemoradiation for bulky, early stage cervical cancer, there was no difference in complication rates between an open or minimally invasive surgical approach. However, the overall complication rate was high, including a high rate of vaginal cuff defect, dehiscence and/or fistulas. Our findings suggest that an adjuvant hysterectomy should be reserved for patients in which chemoradiation is not anticipated to successfully treat the primary tumor and, if performed, an open approach should be considered.

A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service

ObjectiveTo describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution. MethodsPrior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE ‘dashboard’ to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016–2017, 2018, 2019). ResultsCompared to the baseline period, we observed a reduction in VTE rate during the 2018–2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016–2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences. ConclusionsImplementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.

The impact of modern preoperative high-dose-rate brachytherapy in early-stage cervical cancer

PurposeTo analyze the clinical outcomes and the safety of preoperative high-dose-rate (HDR) image-guided adaptive brachytherapy (IGABT) followed by minimally invasive surgery (MIS) in the multidisciplinary management of early-stage cervical cancer. Methods and materialsMedical records of all consecutive patients with early-stage cervical cancer treated at our institution between 2012 and 2018 with preoperative IGABT in a multidisciplinary approach were reviewed. Treatment schedule was pelvic node dissection, preoperative IGABT followed 6–8 week later by MIS hysterectomy. ResultsSeventy patients with cervical cancer FIGO stages (IB1 18.6%, IB2 75.7% and IIA1 5.7%) were treated by preoperative HDR brachytherapy. With a median follow-up of 37.4 months [95% confidence interval, 32.1-39.7 months] isolated vaginal vault recurrence was not observed, 3 pelvic relapses were reported (4.3%). None of patients received postoperative radiotherapy (EBRT) or radiochemotherapy. The estimated 3-year local and pelvis relapse free survival for the entire population were respectively 98% [95% confidence interval, 89%–100%] and 90% [80%–96%]. The estimated 3-year disease-free survival (DFS) for the entire population was 88% [77–94%]. The 3-year overall survival (OS) rate was 97% [88%–99%]. Microscopic vaginal resection margin (R1) was observed in one patient ([1].4%). Lymph-vascular space invasion (LVSI) was found found in 6 (8.6%) patients. Forty-eight late complications in 36 patients (51.4%) were observed. Five (7.1%) grade 3 vaginal wound dehiscence toxicities were observed. Urinary and gastrointestinal toxicities were grade 1–2. No grade 4–5 complications were observed. ConclusionsPreoperative image-guided adaptive brachytherapy followed by minimally invasive surgery allows high local control, reduces positive surgical margins and rates of lymph-vascular space invasion avoiding adjuvants treatments. Surgical approaches must be discussed with patients including preoperative brachytherapy as a down-staging treatment.

Wound dehiscence prevalence and relationship with prosthetic material extrusion in women underwent anterior colpotomy.

Aim:To assess the prevalence of anterior vaginal wall dehiscence in women who underwent anterior vaginal wall colpotomy for pelvic organ prolapse or stress urinary incontinence and to evaluate the influence of suture materials and techniques on wound dehiscence.Materials and Methods:This multicenter, prospective study enrolled naïve women for urogynecological surgery affected by anterior vaginal wall defect or stress urinary incontinence. Performed surgical procedures were anterior vaginal wall repair (AVWR) with native tissue (N-AVWR) or polypropylene mesh (M-AVWR), trans-obturator polypropylene in-out middle urethral sling (MUS). Used suture materials were Vicryl 2-0, Vicryl Rapide 2-0, and Monocryl 3-0. Suture techniques were running interlocking or interrupted. Follow-up was performed daily during hospitalization and in outpatient clinic after 10–14, 30 days, and after 3 months.Results:A total of 1139 patients were enrolled. AVWR were 790: 89.1% N-AVWR, and 10.9% M-AVWR. Polypropylene MUS were 349. Women with prosthetic implantation were 38.2%, while 61.8% had native tissue repair. Overall Vicryl was used in 53.9%, Vicryl Rapide in 37.4%, and Monocryl in 8.7%. Overall running interlocking sutures were 66.5%, while interrupted were 33.5%. Overall wound dehiscence prevalence was 0.9% (10/1139). Wound dehiscence rate of 0.6% (5/790) was documented in AVWR: 0.3% (2/704) in N-AVWR, and 3.5% (3/86) in M-AVWR. Among women underwent MUS, 1.4% (5/349) showed wound dehiscence. In patients who underwent prosthetic surgery, the overall dehiscence prevalence was 1.8% (8/435). A statistically significant higher rate of wound dehiscence was found in women with implanted prosthetic materials.Discussion:We reported for the first time the prevalence of wound dehiscence in females who underwent colpotomy for AVWR or MUS. Wound dehiscence occurrence was low, but non-negligible. We found that this complication was poorly associated to the suture methods and materials, while prosthetic material represented a risk factor for wound healing.

Robotic Radical Hysterectomy for Cervical Adenocarcinoma after Preoperative Brachytherapy in 10 Steps

Minimally invasive surgery decreases postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer. However, a randomized trial and large retrospective data question its safety after observing lower rates of survival than open surgery [1,2]. The causes of this higher recurrence rate are not definitely established but may result from cancer exposure to the peritoneum during vaginal section and cancerous cells' spillage enhanced by pneumoperitoneum or a uterine manipulator. The aim of this surgical video was to present a standardized step-by-step approach for robotic RH according to the recent recommendations from the ARCAGY -Group of National Investigators for the Study of Ovarian and Breast Cancers surgeon's group [3]. Step-by-step video demonstration of the technique. Tertiary center specialized in gynecologic oncology and minimally invasive surgery. A 48-year-old woman was diagnosed with a stage IB2 endocervical adenocarcinoma (International Federation of Gynecology and Obstetrics 2018) with a tumor size of 27 mm. Surgery was planned after preoperative pulsed dose rate uterovaginal brachytherapy. Surgery was performed following 10 reproducible steps: • Pelvic sentinel node identification according to the SENTICOL-III trial • Right infundibulopelvic and round ligaments transection • Right uterine vessels transection • Parametrectomy • Right uterosacral ligament transection • Bladder mobilization • Identical left dissection • Rectovaginal space development • Colpectomy by vaginal route after complete pneumoperitoneum exsufflation • Robotic vaginal cuff closure and pelvic inspection Thorough robotically assisted vaginal cuff closure was carried out as a comparative study suggesting that abdominal closure may decrease vaginal complications and dehiscence [3]. No international recommendations for the RH approach have yet been endorsed. Patients must be clearly informed about the benefit-risk ratio of the surgical route. If a minimally invasive RH is still decided, the patient should be referred to experienced centers, and precautionary measures must be implemented [4]. Colpotomy by vaginal route without pneumoperitoneum is recommended. Uterine manipulators have to be strictly avoided. Preoperative brachytherapy has been reported in experienced centers in France with favorable histologic response with high rates of pathologic complete response (near 70%) and seems particularly worthwhile for tumor sizes ranging from 2 to 4 cm or presenting with lymphovascular invasion [5].

Vaginal Dehiscence and Evisceration After Robotic-assisted Radical Cystectomy: A Case Series and Review of the Literature

To describe a rare complication in 5 women who had vaginal prolapse, dehiscence, and/or evisceration after having undergone robotic-assisted radical cystectomy with creation of ileal conduit urinary diversion. Radical cystectomy is the standard of care in the extirpative treatment for muscle invasive urothelial carcinoma. Anterior exenteration in the female patient requires removal of the anterior vaginal wall, urethra, uterus, and adnexa which results in significant changes to the pelvic floor. Retrospective identification of all women having undergone robotic-assisted radical cystectomy for urothelial carcinoma who ultimately represented with vaginal prolapse, dehiscence, and/or evisceration between January 2012 and April 2019. We identified patient characteristics detailing their presentation. A review of the available literature highlighted the lack of available information in this uncommon cohort. Five women with vaginal dehiscence and/or evisceration who had previously undergone robotic-assisted radical cystectomy, anterior vaginectomy with urethrectomy, pelvic lymph node dissection, and creation of ileal conduit by 4 surgeons were identified. Mean interval time to initial presentation of prolapse or dehiscence was 44.4 weeks (range 11-120). In the 2 patients that eviscerated prior to repair, this occurred at 5 and 25 weeks after initial outpatient consultation. All reconstructive efforts were approached transvaginally. Two patients underwent 2 or more repairs. Management options included expectant management, pessary, and immediate vs delayed transvaginal surgical repair. Our case series describes the unique and potentially devastating complication of vaginal dehiscence and bowel evisceration in women with history of robotic-assisted radical cystectomy.

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Complications and reoperations after laparoscopic radical cystectomy in a Japanese multicenter cohort.

To describe the complications and their surgical management after laparoscopic radical cystectomy in a Japanese multicenter cohort. The participants were drawn from a retrospective multicenter study at 10 institutions. We identified 436 patients who underwent laparoscopic radical cystectomy with no robot assistance. Early and late complications were graded according to their Clavien-Dindo classification. The records of all patients who underwent surgical interventions for laparoscopic radical cystectomy-specific complications were also reviewed. Kaplan-Meier curves were used to describe the time to surgical intervention. The 90-day rates for overall complications, high-grade complications (Clavien-Dindo classification III-V) and mortality were 53%, 17% and 1.4%, respectively. Gastrointestinal (25%), infectious (22%) and abdominal wall-related (9%) complications were the most common. The late complication rate was 18%, and a total of 81 patients (19%) underwent surgical intervention during the median follow-up period of 22months. The reoperation rate was 25% at 5years. Gastrointestinal complications in the early postoperative period and abdominal wall-related complications in the late postoperative period were the main reasons for reoperation. Seven (7%) out of 100 female patients underwent emergent surgical reoperation for transvaginal bowel evisceration as a result of vaginal dehiscence. Early and late postoperative complications and surgical reoperations are notable after laparoscopic radical cystectomy. Abdominal wall-related complications including vaginal dehiscence are common, and they represent the main indication for reoperation during long-term follow up.

An unusual cause of pneumoperitoneum—Traumatic vaginal dehiscence six months after hysterectomy

Introduction: Intraperitoneal free air usually results of the perforation of a hollow viscus. A high degree of suspicion based on previous medical history can identify a gynecologic origin.

LESS with Suture Suspension for Early-Stage Adnexa Cancer Staging.

Background and Objective:Laparoendoscopic single-site surgery has been used in treating gynecologic diseases including early-stage cervical and endometrial cancer, but less so in early-stage adnexal cancer. We aimed to demonstrate the use of laparoendoscopic single-site surgery with suture suspension for staging of early-stage ovarian/fallopian-tube cancer and describe the study results.Methods:Seven patients with early-stage adnexal cancer underwent staging surgery via laparoendoscopic single-site surgery at West China Second University Hospital of Sichuan University from November 2017 to September 2018.Results:All cases were successfully staged via this technique. Two patients underwent the high-level para-aortic lymphadenectomy up to the infrarenal vein, and four patients underwent para-aortic lymphadenectomy at the level of the inframesenteric artery; one patient underwent the para-aortic lymph node sampling. The operation time was 305–365 minutes. The estimated intraoperative blood loss was 50–200 mL. No intra-operative complications occurred; one patient developed pneumonia 48 hours postoperation. The number of pelvic and para-aortic nodes was 15–39 and 1–18, respectively. Pain scores 12 and 24 hours postsurgery were 2–3 and 1–2 with the use of butorphanol tartrate, respectively. On 4–14 months followup, the umbilical incision had good cosmesis; no umbilical hernia or vaginal dehiscence and no neoplasm recurrence were noted.Conclusion:Laparoendoscopic single-site surgery may be a feasible and safe technique for staging early-stage ovarian/tubal cancer. This approach has some advantages included providing easier access to the upper abdominal regions when performing high-level infrarenal para-aortic lymphadenectomy; the 2-cm elastic incision favors fast specimen extraction and colpotomy are avoided. However, the long-term oncologic outcomes need to be further investigated.

Vaginal cuff dehiscence is observed in a higher rate after total laparoscopic hysterectomy compared with other types of hysterectomy.

Recently, it has been suggested that the occurrence of posthysterectomy vaginal cuff dehiscence has increased. Consequently, we evaluated the incidence of vaginal cuff dehiscence after different types of hysterectomies. Our hypothesis is that vaginal cuff dehiscence is more often associated with total laparoscopic hysterectomy (TLH) than other types of uterine removal. A total of 13645 hysterectomies from 1992 to 2015 were evaluated in the Turku University Hospital district, Finland. The primary outcome was occurrence of vaginal dehiscence after different types of hysterectomy. The hysterectomy and postoperative vaginal dehiscence trends were analyzed as the secondary outcome. In a subanalysis of dehiscence cases, women's characteristics and perioperative vaginal cuff opening and closure techniques were compared between conventional hysterectomies (vaginal, abdominal, and laparoscopic with vaginal closure) and TLH. Altogether, 22 cases of vaginal cuff dehiscence were included. Most cases (n=15) occurred after TLH (n=1104), resulting in an incidence of 1.27%. After conventional laparoscopic hysterectomy with vaginal closure (n=2853), vaginal (n=4150), and abdominal (n=5538) hysterectomies, the incidence rates were 0.11%, 0.05%, and 0.02%, respectively. Compared to abdominal hysterectomy, which was associated with the lowest incidence rate, vaginal dehiscence after TLH had an odds ratio (OR) 71.1 (9.34-541.38, P<0.001). In the subanalysis of possible underlying factors, the technique of opening of the vaginal cuff with or without electrocoagulation, duration of operation, and occurrence of postoperative infection or hematoma prior to VCD were observed differences between TLH and conventional hysterectomies. Compared with other types of hysterectomies, vaginal dehiscence was observed at the highest rate after TLH. Studies are needed to define if vaginal opening technique contributes to the risk of dehiscence.

Clermont-Ferrand versus Vectec uterine manipulator for total laparoscopic hysterectomy

Objective: To compare the operation time and performance of two uterine manipulators used for total laparoscopic hysterectomy (TLH).Material and methods: Design: Retrospective cohort analysis. Design classification: Canadian Task Force Classification II-2. Setting: Tertiary-care university-based teaching hospital and academic affiliated private hospital. Patients: All consecutive patients who underwent for TLH between January 2014 and June 2017. All operations were performed by two expert endoscopic surgeons using one of the following uterine manipulators depending on surgeon preferences: Clermont-Ferrand (CF) or Vectec (VT) MAUT60. Patients were excluded if additional surgeries such as urogynecological procedures were performed, TLH was converted to laparotomy prior to colpotomy, and when their operation records could not be obtained. A total of 169 patients were added to final analysis. Operation time, colpotomy time and the subjective performance of manipulators such as movement of the uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were evaluated by watching un-edited operation videos.Results: A total of 169 patients (83 patients in CF group; 86 patients in VT group) were included in the final analysis. Patients’ baseline characteristics were comparable between groups. Operation time and time required for colpotomy were significantly shorter in the VT group. Lateral movements of the manipulators and elevation of the uterus were better with VT compared to CF (p = .001 for both). Compared to the CF, VT was superior for visualization of the vaginal fornices (p = .004) and maintenance of pneumoperitoneum (p < .001). Both surgeons had perfect agreement on the performance grading of manipulators (p < .001, Kappa values were between 0.86–0.92). There was no difference between groups in estimated blood loss and duration of hospital stay. Reinsertion or the need to change the manipulator was not required in either group. No pelvic or vaginal abscess, cuff cellulitis, dehiscence, or hematoma formations were noted.Conclusion: Laparoscopic hysterectomy assisted with the VT uterine manipulator is associated with shorter operation and colpotomy time. Furthermore, the movements of uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were significantly better with VT compared to the CF manipulator.

Hysterectomy by vaginal-assisted natural orifice transluminal endoscopic surgery: Initial experience with twelve cases.

Objective:To declare our initial experience on hysterectomy cases performed using vaginally-assisted natural orifice transluminal endoscopic surgery.Material and Methods:The study was conducted with data from 12 patients in our department who were recommended for hysterectomies for various indications between January 2017 and May 2017. The following data were collected retrospectively: age, body mass index (BMI), parity, previous abdominal or pelvic surgery, total operating time, preoperative hemoglobin (Hb), postoperative Hb, peri-operative complications and Visual Analogue Scale scores for evaluating postoperative pain. All patients were laid in the dorsal lithotomy position under general anesthesia. A cervical circumcision, as well as anterior and posterior colpotomy were performed. A self-constructed glove port was then inserted through the anterior and posterior colpotomy openings into the abdominal cavity. After pneumoperitoneum was achieved, a 10-mm rigid zero-degree telescope, disposable conventional laparoscopic grasping forceps, and a tissue sealer were used as standard equipment. After exploration of the abdominal cavity, all uterine vessels and ligaments were sealed and transected using the tissue sealer. After removing the uterus, the vaginal opening was closed using a Vicryl 1-0 suture.Results:The following are the mean values for each variable: patients’ age: 55.75±9.8 years (range, 43-72 years), BMI: 29.4±5.4 kg/m2 (range, 21-42 kg/m2), operation duration: 66.8±25.3 min (range, 42-120 min), decrease in Hb: 1.5±1 (0-4) gr/dL, and hospital stay: 2.1±0.3 (2-3) days. There were no vaginal wound infections or dehiscence, and no patients reported pain during postoperative pelvic examinations. Conclusion:Although these findings are from our initial experience, we can affirm the feasibility of this technique.