Vaginal Packing Research Articles

Advanced Strategies for Hemorrhage Management in Cesarean Sections An In-Depth Procedural Guide

Over the past five decades, there has been a substantial global increase in cesarean section rates. Unfortunately, the incidence of maternal morbidity following cesarean delivery remains notably high, reaching levels as elevated as 36%. Among the prevalent complications are febrile episodes (25%), hemorrhage (4%), hematoma formation (4%), and urinary tract infections (3%). Obstetric hemorrhage, in particular, stands out as a leading cause of maternal mortality worldwide. Excessive bleeding, defined as a blood loss exceeding 1000 ml during cesarean sections, is frequently underestimated, yet it is documented in over 5-10% of such procedures. While conservative management, including vaginal packing and the administration of uterotonic agents, is effective in many instances, persistent hemorrhage may necessitate specific surgical interventions. Therefore, a comprehensive understanding of the procedural steps for managing bleeding during cesarean sections is crucial to mitigating maternal mortality. This review article aims to consolidate various techniques employed to control hemorrhage during cesarean deliveries.

Prevention of intrauterine balloon displacement in patients with postpartum hemorrhage: A narrative review.

Postpartum hemorrhage (PPH) remains a significant complication of pregnancy globally, with uterine atony accounting for the great majority of cases. Second-line hemostatic strategies such as uterine balloon tamponade play a crucial role in managing refractory hemorrhage. Despite its effectiveness, the phenomenon of balloon displacement poses a challenge to PPH management, often leading to treatment failure. Various techniques have been proposed to address this issue, including vaginal packing, cervical cerclage, fixation to the abdominal wall, holding the cervix with ring forceps, and suspending the balloon with cervical sutures. Each method has its advantages and limitations, influencing its suitability in different clinical scenarios. Understanding these techniques may be useful to optimize and improve the management of PPH and maternal outcomes. This review provides a comprehensive summary of these strategies, their mechanisms, and their clinical implications, aiming to guide healthcare providers in choosing the most appropriate approach for individual cases of PPH.

Avoiding Packing When an External Fixator Is Used in Cervical Cancer Brachytherapy: The Rationale for Vaginal Gauze Packing on Rectum and Bladder

Avoiding Packing When an External Fixator Is Used in Cervical Cancer Brachytherapy: The Rationale for Vaginal Gauze Packing on Rectum and Bladder

Vaginal Packing After Pelvic Floor Reconstructive Surgery: Does the Soaking Agent Used for Packing (Bupivacaine, Estrogen or Saline) Impact Postoperative Pain Scores?

Study ObjectiveVaginal packing is traditionally placed after pelvic floor reconstructive surgery (PFRS) to prevent hematoma formation. We seek to determine if there is a difference in post-operative pain scores after PFRS if vaginal packing is soaked with estrogen cream, bupivacaine, or saline. The primary outcome was pain as measured by a visual analog scale (VAS) at 2 hours, 6 hours, and 1 day post-operatively. Secondary outcomes include change in hemoglobin, urinary retention and length of stay (LOS) in hospital. DesignProspective cohort study SettingTertiary care academic teaching hospital. All PFRS performed by fellowship-trained urogynecologists. ParticipantsConsenting patients undergoing PFRS. InterventionsAt the completion of surgery, gauze packing soaked with either estrogen cream 0.25% bupivacaine with 1% epinephrine, or normal saline was placed inside the vagina and removed on post-operative day 1. ResultsWe included 210 patients (74 estrogen, 66 bupivacaine, 70 saline). There was no significant difference in mean post-operative pain scores between the groups (estrogen, bupivacaine, saline-soaked vaginal packs respectively) at 2 hours (2.66±2.25, 2.30±2.17, 2.24±2.07; p=.4656), 6 hours (2.99±2.38, 2.52±2.30, 2.36±2.01; p=.2181) or on post operative day 1 (1.89±2.01 vs. 2.08±2.15 vs. 2.44±2.19; p=.2832) as measured by VAS scores (0-10). There was no difference in the secondary outcomes of change in pre-/post-operative hemoglobin (21.8±10.73g/L, 20.09±11.55g/L, 21.7±9.62g/L, p=.68), urinary retention (37%, 45% and 48%, p=.45), LOS (1.05±0.46 days, 1.02±0.12, 1.03±0.24, p=.97) or in-hospital opioid usage during admission (represented in morphine milligram equivalents (median (IQR1, IQR3), Kruskal-Wallis test): 11.25mg (0,33), 7.5mg (0, 22.5) and 15mg (0, 33.88) p =0.41. ConclusionThere was no difference found between soaking vaginal packing with estrogen cream, bupivacaine, or saline after PFRS with respect to post-operative pain scores, LOS, in-hospital opioid usage, or urinary retention. Saline-soaked packing is an equivalent alternative to estrogen or bupivacaine vaginal packing. Clinical Trial RegistrationNCT03266926. Registered February 1, 2017. https://clinicaltrials.gov/study/NCT03266926

Uterine isthmic tourniquet left insitu as a new approach for placenta previa-accreta surgery: a comparative study.

Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta. In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation. This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69±1.37 vs. 8.15±1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018). The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone.

Early Removal of Indwelling Catheter and Vaginal Pack After Vaginal Prolapse Surgery: A Retrospective Cohort Study.

After vaginal pelvic organ prolapse (POP) surgery a vaginal pack and indwelling bladder catheter are inserted to reduce blood loss and bladder overdistension. The ideal timing of removal remains unclear. In this study we compared removal of vaginal pack and indwelling catheter 3 h post-surgery with removal the next day. This retrospective cohort study performed in the Netherlands included patients undergoing POP surgery between 1 January 2019 and 31 December 2020. Patients in whom the vaginal pack and catheter were removed the day after surgery (group A) were compared with patients in which the vaginal pack and catheter were removed 3h post-surgery (group B). Both groups were compared regarding urinary retention and the need for re-intervention owing to active blood loss within 6weeks postoperatively. Baseline characteristics, such as age, type of operation and type of anaesthesia in group A (n = 280) and group B (n = 207) were comparable. No significant differences were found regarding complications such as urinary retention (17.2 versus 23.2%; p = 0.255). The rates of re-intervention because of active blood loss and occurrence of infection were also comparable. Removal of the indwelling catheter and vaginal pack 3h after vaginal POP surgery does not lead to more postoperative complications than removal the 1st day after surgery. Therefore, early removal is a feasible and safe alternative to the standard timing of removal the morning after surgery of women undergoing POP surgery. In the future this could help with introducing same-day discharge.

A randomized trial evaluating a novel hydrogel packing system compared to standard packing during image-guided high-dose rate brachytherapy boost for cervical cancer

INTRODUCTIONThe purpose of this prospective randomized trial was to compare the use of a novel vaginal hydrogel packing system (BrachyGel) to standard vaginal packing (VP) during high dose rate (HDR) brachytherapy (BT) for locally advanced cervical cancer (LACC). METHODSThis cross-over study included LACC patients receiving HDR BT boost (intracavitary +/- interstitial). All patients received alternating gauze or BrachyGel VP on Arms A and B. Patients, physicians, and physicists evaluated BT characteristics via a 4-point Likert scale. Adverse events (AEs) were prospectively collected and scored per CTCAE. RESULTSThe 20 patients enrolled. The mean bladder D2cc difference between gauze and BrachyGel in Arm A was 0.117 Gray (Gy) and in Arm B 0.013 Gy. The mean difference in rectum D2cc in Arm A and Arm B was -0.189 Gy and -0.191 Gy, respectively. The mean dose to 90% of the high-risk clinical target volume (HR-CTV) for gauze compared to BrachyGel was -0.032 Gy (95% CI: 0.472, 0.409). Patient-reported discomfort was similar with BrachyGel and gauze (“mild/moderate” 70.0% vs 74.0%, respectively). The clarity of VP was similar between BrachyGel and gauze (86.8% vs 89.7%, respectively). The completeness of VP was more frequently “excellent/good” with BrachyGel (79.0%) compared to gauze (56.4%). The ease of packing was more frequently “extremely easy” with BrachyGel (21.2% vs 0%). No serious AEs were reported. CONCLUSIONThis randomized trial found no clinically significant difference in OAR or HR-CTV dosimetry between BrachyGel and standard VP. BrachyGel performed well compared to gauze for the patient and physician use experience.

Importance of vaginal packing after laparoscopic sacrocolpopexy - retrospective study.

To compare the subjective and objective results of laparoscopic sacrocolpopexy (LSC) with and without the introduction of a vaginal packing one year after surgery.Methodology:This is a retrospective cohort study of 125 women after laparoscopic sacrocolpopexy operated on in 2013-2016 with complete annual follow-up. Patients with a total hysterectomy were excluded from the study. Basic patient characteristics, preoperative POP-Q and surgery data were collected. The subjectiveoutcome of the surgery was assessed using the PGI-I (patient global impression of improvement). The anatomicoutcome of the surgery was evaluated using the composite definition of surgical failure based on POP-Q (Ba ≥ -1, C ≥ -3, Bp ≥ -1). Patients were divided into two groups according to whether or not they had vaginal packing after surgery. Statistical analysis was performed usingc2, Wilcoxon and Fischer test according to the distribution of normality.Results:A total of 125 women were enrolled in the study; 48 (38.4%) after LSC, 58 (46.4%) with concomitant supracervical hysterectomy and 19 (15.2%) after sacrohysterocolpopexy. Vaginal packing was introduced for 24-48 hours after surgery in 86 (68.8%) women. The groups did not differ in age, body mass index, smoking or preoperative pelvic organ prolapse quantification system. We did not observe statistically significant differences in PGI-I first year after surgery. The difference in anatomic surgical failure did not reach statistical significance, although more failures were observed in the group without packing (12.8 vs. 3.5%; P = 0.09). The mean C-point value one year after surgery was lower in the non-tamponade group (-7 vs. -7.5; P < 0.009). No mesh extrusion or serious complications were recorded in the monitored group.Conclusion:Vaginal packing after LSC probably does not affect patient satisfaction after surgery, however, it may be associated with better anatomicaloutcome one year after the surgery. The results of the study must be confirmed by a more detailed prospective evaluation.

Outcome of vesicovaginal fistula repair by vaginal approach.

Objectives: To evaluate success of vesicovaginal fistula repair by vaginal approach with secondary objective to assess the limitations of repair by vaginal route. Study Design: Retrospective & Descriptive study. Setting: Department of Urology and Renal Transplantation, Faisalabad Medical University, Faisalabad. Period: January 2017 to December 2020. Material & Methods: In which 42 patients were included in the study. All patients were submitted for VVF repair by vaginal approach. Procedure was done under spinal anesthesia in all patients. Operation was done in lithotomy position. Circumferential incision was made around the fistula. Vagina and bladder were separated. Urinary bladder was repaired in two layers and vagina by perpendicular stitching technique. Foley catheter was passed. Urinary leakage was seen by instillation of normal saline and Gentian Violet. Vaginal packing was done at the end of the procedure which was removed after 1 day of surgery and patient post operative data was noted. Results: 42 patients were included. There mean age was 27 years. 45.23% patients came with history of prolonged labor, 30.95% patients presented after transabdominal hysterectomy, 21.42% after lower segment secession section and 2.38% patients came after operation for cystocele. Infra-trigonal VVF was present in 59.53% patients and supra-trigonal in 40.47% cases. Our success rate was 85.71% and we faced failure in 14.28% of patients. Lower urinary tracts symptoms were seen in 30.95%, hematuria in 9.25%, stress incontinence in 11.9%, symptoms like over active bladder in 7.14% and urinary tract infection in 14.28%. Conclusion: VVF repair by vaginal approach is safe and successful with less morbidity than abdominal approach.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

A national survey of UK practice for day-case vaginal prolapse surgery: Unrealistic expectations?

ObjectiveThe UK NHS Getting It Right First Time report (2021) recommended that a significant proportion of native tissue vaginal prolapse operations should be undertaken as day-case procedures (target: 80% anterior compartment, 70% posterior compartment, 60% combined anterior/posterior compartment). The evidence for perioperative care, options for anaesthesia and outcomes of day-case vaginal prolapse surgery is limited. This study aimed to establish current practice amongst UK gynaecologists and explore perceived barriers to implementing day-case surgery for pelvic organ prolapse.Study designA pre-tested 16-item survey was emailed to British Society of Urogynaecology members in July 2022. This survey recorded rates of day-case prolapse surgeries, barriers to implementation and practices for managing urethral catheters, vaginal packs, intraoperative anaesthetics and perioperative care. Responses to free-text questions were independently analysed by two of the authors and underwent thematic analysis. Results121 eligible responses were received (28 % response-rate): 41 % never undertook day-case prolapse repair, 16 % undertook < 5 per year and 26 % undertook > 20 cases per year. There was no significant difference in training level or hospital setting between those groups. Reasons cited for not undertaking day-case prolapse surgery included concerns about vaginal packs and urinary catheters (92 %) postoperative complications (67 %), early discharge of elderly patients (60 %) and a lack of published evidence (39 %) or national guidance (35 %). For those currently undertaking day-case prolapse surgery; 67 % used general anaesthesia, 15 % spinal with short-acting local anaesthetic, 14 % spinal with long-acting local anaesthetic and 3 % local anaesthetic alone. Vaginal packs and self-retaining urethral catheters were used by 68 % and 70 % respectively. Concerns regarding the management of vaginal packs and urinary catheters were the most frequently cited barrier to implementing day-case surgery for pelvic organ prolapse amongst free-text responses. There were wide variations in managing catheters and packs, and in managing readmissions. ConclusionsThere is significant variation in uptake and practice for day-case prolapse surgery in the UK, with legitimate clinical concerns a barrier to its implementation. Further evaluation and development of robust, evidence-based management pathways are required to make day-case prolapse surgery consistent, feasible and defensible in clinical practice.

Current Clinical Practice Patterns in Total Vaginal Hysterectomy.

There are no data on current surgical practice patterns for benign total vaginal hysterectomy (TVH) despite recently published guidelines. The objective was to determine gynecologic surgeon practice patterns regarding TVH perioperative interventions and to assess adherence to clinical practice guidelines. A survey to assess TVH practice patterns was distributed to gynecologic surgical society members for completion. The primary outcome was to compare adherence to practice guidelines between fellowship-trained and non-fellowship-trained gynecologic surgeons. Secondary outcomes included comparing adherence based on age, practice location, and hysterectomy volume. Of the 204 respondents, there were 163 (80%) fellowship-trained and 41 (20%) non-fellowship-trained gynecologic surgeons. Fellowship-trained surgeons were more likely than non-fellowship-trained surgeons to use vaginal packing (34% vs 15%, P = 0.028), which is contrary to the recommendations. No cohort followed the guideline recommending a circular cervicovaginal incision. Fellowship-trained surgeons also were more likely than non-fellowship-trained surgeons to use the clamp and suture technique for vessel ligation (88% vs 68%, P = 0.004); otherwise, there were no significant differences between cohorts for adherence to any of the other guidelines. Although fellowship-trained surgeons were adherent to fewer of the guidelines as compared with surgeons without fellowship training, both groups generally adhered to a majority of the clinical practice guidelines for benign TVH. This information demonstrates a need for the development of targeted education and interventions to increase the use of evidence-based clinical practice guidelines during TVH for both fellowship-trained and non-fellowship-trained gynecologic surgeons.

Outcome of Transvaginal Local Repair of Vesicovaginal Fistula

Background: Vesicovaginal fistula (VVF) is a significant cause of physical &amp; psychological disability with social stigmatization especially in low- and middle-income countries. Over 80% of such cases result from neglected prolonged and obstructed labour. Objective: The purpose of the study was to observe the outcome of transvaginal local repair of vesicovaginal fistula (VVF). Methods: This descriptive study was carried out at the Department of Obstetrics &amp; Gynaecology, Sylhet M.A.G. Osmani Medical College Hospital, Bangladesh, from July 2007 to June 2008, on 50 patients of vesicovaginal fistula. We included women who were suffering from VVF and who were operated before and diagnosed as a failed repair of VVF. We excluded those patients who had VVF with associated problem like rectovaginal fistula (RVF), any repair through transabdominal route and unwilling to take part in this study. Before surgery, each woman was assessed by medical and surgical history, examination and necessary investigations. Typically, regional anesthesia was utilized for the fistula surgery. However, general anesthesia was given when required. During surgery, transvaginal approach was taken for repair. The vagina was packed for haemostasis. Vaginal pack was removed after 1-2 days depending on instruction of the surgeon. Repacking of vagina was also done sometimes when there was some leaking during post-operative period. Few patients developed severe constipation post operatively. Results: The participants aged between 16 and 70 years. Among them, majority of the patient belongs to the age 31-35 years (26%) followed by 2nd common group 26-30 years of age (20%) and 3rd one in between 21-25 years of age (16%). Among them 44% patients were primipara and 22% patients were grand multipara. The mobilization during operation was excellent in 30%, satisfactory 64% cases and not enough in 6% cases. After mobilization fistula closed in double layer in 10% and in single layer 90% cases, labial fat graft was given 38% and peritoneal graft was given in 2% cases. During operation bleeding was minimum in 92% cases and in 34% cases catheter was block, urine leakage occurred in 30% cases. Among all patients 14% suffered from fever postoperatively. There was vaginal discharge in 10% cases and UTI in 12%cases which was evidenced by urine culture. Operation was fully successful in 60 percent cases, urethral incontinence in 22% cases &amp; failed in 18% women. Conclusion: In this study, majority of the transvaginal local repair of VVF operations were successful; however, few difficult cases were observed. Mugda Med Coll J. 2023; 6(1): 25-29

V04-03 COMBINED ROBOTIC TRANSPERITONEAL AND TRANSVAGINAL PULL-THROUGH FOR REPAIR OF DISTAL VAGINAL ATRESIA: A VIDEO CASE REPORT

You have accessJournal of UrologyCME1 Apr 2023V04-03 COMBINED ROBOTIC TRANSPERITONEAL AND TRANSVAGINAL PULL-THROUGH FOR REPAIR OF DISTAL VAGINAL ATRESIA: A VIDEO CASE REPORT Jeremiah Dallmer, Peris Castaneda, Andrew Freedman, and Paul Kokorowski Jeremiah DallmerJeremiah Dallmer More articles by this author , Peris CastanedaPeris Castaneda More articles by this author , Andrew FreedmanAndrew Freedman More articles by this author , and Paul KokorowskiPaul Kokorowski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Distal vaginal atresia is a unique Mullerian pathology where the urogenital sinus, responsible for the lower 1/3 of the vagina, fails to cannulate during development. Unlike Meyer-Rokitansky-Kuster-Hauser syndrome, which is characterized by agenesis of the upper vagina and uterus, patients with distal vaginal atresia have normal Mullerian development including the uterus and proximal vagina. METHODS: We present the case of a 12 yo female with a three month history of cyclical abdominal pain. Upon outside workup, she was found to have a short, blind ending vagina. MRI showed a 9 cm x 8 cm dilated uterus, open cervix and proximal vagina filled with blood products. She was taken to the operating room for combined perineal and robotic transperitoneal pull-through. RESULTS: An 8.5 mm camera port was placed in the umbilicus and three 8.5 mm working ports were placed using a hidden incision approach below the belt line. We incised the peritoneum and dissected as distally as feasible along the rectovaginal space. At the blind-ending introitus, a U-shaped incision was made to create an anterior flap. This space was dissected proximally, monitoring the correct plane via a finger in the rectum and with direct visualization with the robotic camera. The two planes were connected. A 0-silk was robotically placed to manipulate the vagina. As the vagina was severely dilated from menstrual products, mobility was insufficient to reach the introitus. A small posterior incision on the proximal vagina was made and blood products were partially evacuated. The vesicovaginal space was then dissected robotically, maintaining the lateral attachments as blood supply and avoiding ureteral injury. The vaginal apex was then pulled to the introitus and anastomosed to the anteriorly based flap from the introitus. The patient remained hospitalized for two days with vaginal packing in place. She was trained in the use of vaginal dilators and has been progressively increasing the size without difficulty. CONCLUSIONS: Robotic dissection of the proximal vagina in the setting of distal vaginal atresia using a hidden incision approach allows for orthotopic reconstruction, and superior aesthetics as compared to traditional port placement. This approach obviated the need for the use of tissue grafting or more extensive open dissection. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e338 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremiah Dallmer More articles by this author Peris Castaneda More articles by this author Andrew Freedman More articles by this author Paul Kokorowski More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP)

You have accessJournal of UrologyCME1 Apr 2023V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP) Arman Walia, Vi Nguyen, Aditya Bagrodia, and Jennifer Anger Arman WaliaArman Walia More articles by this author , Vi NguyenVi Nguyen More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile inversion vaginoplasty is a common technique for feminizing gender-affirming surgery in which a vaginal canal can be created from full thickness scrotal skin graft. Based on surgeon preference or when scrotal skin is limited, the Davydov technique described for patients with vaginal agenesis can be used (Zhao et al). In this approach, the proximal canal is formed from peritoneum as a peritoneal cap. However, a peritoneal cap may not necessary in those with adequate graft length. Here we demonstrate a modified Davydov technique is which the apex of the vaginal canal is closed and peritoneal flaps are utilized for coverage and blood supply only, rather than inclusion as the neovaginal apex. METHODS: We utilized a standard pelvic robotic port placement using the Da Vinci Xi. Side docking allows for perineal dissection and penile disassembly. Posterior dissection is performed similar to robotic prostatectomy. The peritoneum is incised and Denonvillier’s followed. The perineal surgeon directs the robotic surgeon in avoiding the rectum. Under vision from above the perineal surgeon enters the dissected space. With guidance from below, the robotic surgeon separates the lateral levator muscle until the opening is calibrated to vaginal stent diameter. Vaginal packing can be placed to facilitate remaining perineal work. The lateral peritoneal flaps are created by incising peritoneum over the external iliac artery distally. Flap length is assessed to avoid constriction over the sigmoid, and further released as needed. After confirming adequate length, the canal is delivered from below. The apex can be closed prior to delivery or robotically. The anterior peritoneal flap is harvested by continuing the lateral dissections in an inverted "U". The lateral flaps are then secured to the canal with barbed suture. Depending on patient anatomy, the anterior flap can be rotated for coverage or simply advanced posteriorly. The anterior and posterior peritoneal flaps are then approximated over the canal apex to provide blood supply to the graft. RESULTS: The above technique has been applied to our last 5 penile inversion vaginoplasty patients. Each had an unremarkable postoperative recovery and is doing well at follow up. CONCLUSIONS: Gender-affirming surgery is a growing field with evolving techniques. A robotic-assisted approach provides additional visibility and maneuverability. A modified Davydov technique for peritoneal coverage can be added to our surgical repertoire for patients with adequate canal length so that the vaginal graft can be fully closed at the apex. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arman Walia More articles by this author Vi Nguyen More articles by this author Aditya Bagrodia More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

Dosimetric comparison of rectal dose-reductive techniques in intra-cavitary brachytherapy for cervical cancer: A retrospective analysis.

Rectal complications in radiotherapy for cervical cancer can highly affect quality of life and correlate with rectal dose. Vaginal gauze packing (VP) and rectal retraction (RR) are widely used for rectal dose reduction in high-dose-rate brachytherapy. We aimed to perform a dosimetric comparison of these two methods for three-dimensional image-guided adaptive brachytherapy. We retrospectively examined 50 patients with cervical cancer treated with definitive radiotherapy, including intra-cavitary brachytherapy, performed with VP and RR. We extracted two fractions for each patient: one fraction with VP and the next fraction with RR, and then compared dose-volume parameters. In total, 50 fractions each were analyzed in VP and RR groups. Dose to 90% (D90) of high-risk clinical target volume (HR-CTV), and minimum dose to most exposed 2.0 cm3 of other organs at risk (D2cm3) for the rectum and bladder were determined from planning computed tomography. There were no significant differences between VP and RR in D90 of HR-CTV (mean: 7.479 Gy and 7.652 Gy, respectively, p = 0.172). The D2cm3 values for the rectum (mean: 4.234 Gy vs. 4.627 Gy, p = 0.008) and bladder (mean: 5.959 Gy vs. 6.690 Gy, p < 0.001) were significantly lower with VP compared with RR. VP reduced the dose to the rectum and bladder when compared with RR without impairing the dose to CTV.

Feasibility of outpatient hybrid brachytherapy for cervical cancer with minimal sedation: Results from a single-institutional protocol.

Pain control techniques during high-dose-rate hybrid intracavitary-interstitial brachytherapy (HBT) for cervical cancer vary widely, with many centers opting for general anesthesia (GA) or conscious sedation (CS). Here, we describe a single-institutional series of patients treated with HBT and ASA-defined minimal sedation, utilizing oral analgesic and anxiolytic medications in substitution for GA or CS. The charts of patients who underwent HBT treatments for cervical cancer from June 2018 to May 2020 were retrospectively reviewed. Prior to HBT, all patients underwent an exam under anesthesia (EUA), and Smit sleeve placement under general anesthesia or deep sedation. Oral lorazepam and oxycodone/acetaminophen were administered between 30-90 minutes before HBT procedure for minimal sedation. HBT placement was performed on computed tomography (CT) table, with needle advancement under CT-guidance. Treatments with minimal sedation were attempted in 63 patients. A total of 244 interstitial implants with 453 needles were placed via CT-guidance. Sixty-one patients (96.8%) tolerated the procedure without any additional intervention, while two patients (3.2%) required the use of epidural anesthesia. None of the patients in the series required a transition to general anesthesia for the procedure. Bleeding, which resolved with short-term vaginal packing, occurred in 22.1% of insertions. In our series, the treatment of HBT for cervical cancer with minimal sedation was feasible at a high percentage (96.8%). The ability to perform HBT without GA or CS could be a reasonable option to provide image-guided adaptive brachytherapy (IGABT) with limited resources, allowing for more widespread use. Further investigations using this technique are warranted.

CASE STUDY OF A PARAVAGINAL HAEMATOMA FOLLOWING VAGINAL DELIVERY

We present the case of a primigravida who had an induced delivery for mild IUGR at 38+6weeks. She had a normal vaginal delivery with right mediolateral episiotomy and minimal vaginal bleeding. She complained of increasing rectal pain in the postpartum period. Vaginal examination revealed a large left sided vaginal haematoma with intact episiotomy wound site.The haematoma was evacuated ,wound exploration done and sutured in layers. Vaginal packing was done. Postoperatively she again complained of rectal pain. Urgent CT scan conrmed nding of a large left pararrectal haematoma with possibility of small left broad ligament extension. She was managed conservatively with vaginal and rectal packing, analgesics,intravenous antibiotics and 3units of packed red cell transfusion. Follow up ultrasound showed reduction in the size of the haematoma and eventual resolution. This case supports the conservative management of even large paravaginal haematomas, when surgical evacuation is technically difcult as long as the patient is clinically stable.

8 Hybrid intracavitary and interstitial brachytherapy for cervical cancer in the outpatient setting

Image-guided hybrid intracavitary and interstitial brachytherapy (HBT) for the treatment of locally advanced cervical cancer may improve outcomes compared to intracavitary brachytherapy alone. Pain control is usually achieved with general anesthesia (GA), which increases both treatment duration and the risk of complications with each treatment. Here we detail the results of our institution's protocol with CT-guided interstitial needle placement, utilizing minimal sedation. A single-institutional database of patients who underwent HBT for cervical cancer from June 2018 to May 2020 was queried. Patterns of anesthesia usage, step-by-step procedural times, medication usage, and treatment-related complications were reviewed. All patients had a Smit sleeve placed in the OR under GA days before their first HBT treatment. Prior to HBT, patients received minimal sedation, composed of oral lorazepam and hydrocodone/acetaminophen. Tandem and ovoids were inserted and interstitial needles were placed under CT guidance. The patients were moved from the CT table to a surgical bed, and then to the radiation vault for treatment delivery. The applicator was then removed and vaginal packing was inserted if any bleeding occurred. A total of 244 implants were placed in 63 patients under minimal sedation. 61 patients (96.8%) tolerated the procedure, 2 (3.2%) required epidural anesthesia, and 0 required transition to GA. The median time for the entire procedure (CT room entry to exit of the HDR room) was 70.0 mins (mean 70.3 mins, range 54–100 mins). The median time for the interstitial needle insertion portion was 9.0 mins (mean 9.8 mins, range 4–24 mins). Bleeding occurred in 54 (22.1%) implants, which resolved after 3 minutes of vaginal packing (mean 3.33 mins, range 1–8 mins). Our outpatient HBT protocol was efficient and well-tolerated, with reasonable bleeding rates which were minimal and quickly resolved. HBT with minimal sedation was achievable at a high percentage (96.8%). The performance of HBT without GA may reduce treatment time, costs, and anesthesia-related adverse effects. Treatment with minimal sedation has the potential to enable more universal use of HBT, improve brachytherapy dosimetry, and enhance patient outcomes. Further investigation is warranted.