Vaginal Reconstructive Surgery Research Articles

Outcomes of bladder outlet obstruction following extensive vaginal pelvic reconstruction surgery on patient with advanced pelvic organ prolapse.

To evaluate the impact of extensive vaginal pelvic reconstruction surgery (PRS) on advanced pelvic organ prolapse (POP) patients with bladder outlet obstruction (BOO). We conducted a single-center, retrospective analysis of women who received extensive vaginal pelvic reconstruction surgery for advanced POP (POP-Q ≥3) with BOO from January 2006 to January 2016. Data regarding preoperative evaluation, surgical procedure, and postoperative management were abstracted from medical records. Patients were considered to have BOO when detrusor pressure at maximum flow (Dmax) was ≥20 cm H2O and peak flow rate (Qmax) was ≤15 mL/s. Patients with postoperative value of Dmax lower than 20 cm H2O or Qmax higher than 15 mL/s were regarded as objectively cured. A total of 1894 patients with POP stages III or IV were assessed. The incidence of BOO was 22.8% (431/1894) within this patient population of advanced POP. One year after the vaginal PRS, the objective cure rate of BOO was 98.1%. Urodynamic parameters showed a significant increase in Qmax (P < 0.001), while Dmax (P < 0.001) and postvoid residual urine (PVR) (P < 0.001) were significantly decreased. Previous POP surgery, native tissue repair (NTR), PVR ≥200 mL, and maximal cystometric capacity (MCC) ≥500 mL increase the likelihood of persistent BOO in patients. Vaginal PRS demonstrated effectiveness in treating BOO in patients with advanced POP. Irrespective of the types of transvaginal mesh (TVM), using TVM achieved better outcome than did NTR. Previous POP surgery, preoperative PVR ≥200 mL, and MCC ≥500 mL were the risk factors predicting the failure of PRS in improving BOO.

Pudendal Block at the Time of Transvaginal Prolapse Repair: A Randomized Controlled Trial.

The utility of pudendal nerve blocks (PNBs) at the time of transvaginal surgery is mixed in the literature. No published study has evaluated the efficacy of PNB since the widespread adoption of Enhanced Recovery After Surgery (ERAS) pathways. This study aimed to determine if PNB, in addition to ERAS measures, at the time of vaginal reconstructive surgery reduces opioid use in the immediate postoperative period. In this randomized, blinded, controlled trial, women scheduled for transvaginal multicompartment prolapse repair were randomized to bilateral PNB before incision with 20 mL of 0.5% bupivacaine versus usual care. Primary outcome was opioid use in morphine milligram equivalents (MME) for the first 24 hours. The study was powered to detect a 5.57-MME difference in opioid use in the first 24 hours between groups. Forty-four patients were randomized from January 2020 to April 2022. The PNB and control groups were well matched in demographic and surgical data. There was no difference in opioid use in first 24 hours between the control and PNB groups (8 [0-20] vs 6.7 [0-15]; P = 0.8). Median pain scores at 24 and 48 hours did not differ between groups (4 ± 2 vs 3 ± 3; P = 0.44) and 90% of participants were satisfied with pain control across both groups. Time to return to normal activities (median, 10 days) was also not different between the groups. Because pain satisfaction after transvaginal surgery in the era of ERAS is high, with overall low opioid requirements, PNB provides no additional benefit.

Complications of obliterative versus reconstructive vaginal surgery for pelvic organ prolapse in octogenarians: A retrospective cohort study.

Women of advanced age may choose between restorative or obliterative surgery for surgical management of pelvic organ prolapse. Obliterative surgery is traditionally reserved for a subset of older women with more severe medical comorbidities, since obliterative approaches are generally considered to be less morbid and older individuals have higher rates of perioperative complications than younger cohorts. This study compared perioperative complications amongst octogenarians undergoing obliterative versus reconstructive approaches. This data will help to inform perioperative counselling as previous studies have not been powered to evaluate complications in this population. The National Surgical Quality Improvement Program database was used to identify patients that had Pelvic organ prolapse surgery between 2012 and 2021, aged 80 years or older. Single-compartment procedures, vaginal mesh procedures, and oncologic surgery were excluded. The primary outcome was any complication within the first 30 days excluding urinary tract infection (UTI). UTI, readmission, and severe complications were secondary outcomes. Of the 4149 patients identified, 2514 (60.6%) underwent reconstructive surgery and 1635 (39.4%) underwent obliterative surgery. Patients undergoing reconstructive surgery were more likely to have an American Society of Anesthesiologists (ASA) class of 1 or 2 (46.1% vs. 31.3%, p = 0.002) and were less likely to be on antihypertensive medication (72.0% vs. 75.8%, p = 0.006). Further, there was an increased length of stay (1.47 ± 1.84 vs. 1.03 ± 1.31 days, p < 0.001) in hospital for reconstructive surgery which was more often performed as an inpatient (45.7% vs. 37.9%, p < 0.001). There was no difference in the primary outcome: any complication excluding UTIs. However, UTI was more common in the reconstructive group (aOR 0.48; 95% confidence interval 0.34-0.0). The rate of serious complications (Clavien-Dindo Class IV) was low overall and not different between reconstructive and obliterative approaches (1.3% vs. 1.0%, respectively). Both vaginal reconstructive and obliterative approaches have low complication rates in octogenarians, with only UTIrate being different between cohorts. When choosing surgical approach, we suggest a case-based, patient center discussion on the anatomic outcomes, durability and patient satisfaction.

The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training

ABSTRACT In the United States, around 9 million women are affected by pelvic pain due to conditions such as interstitial cystitis/bladder syndrome, fibromyalgia, pelvic floor myalgias, chronic opioid use, or irritable bowel syndrome. Treatment options for concurrent pelvic floor disorders and pelvic pain can prove challenging due to the overall desire to avoid exacerbating overall pain while optimizing pelvic floor symptoms. The primary aim of this study was to compare both perioperative pelvic muscle training and vaginal reconstructive surgery among women who experienced or lacked preoperative pain and to inform better approaches to management of women with preoperative pain. The study was a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) randomized clinical trial, as performed via the Pelvic Floor Disorders network. The main study's design was a 2 × 2 randomized factorial design with a surgical intervention and a perioperative behavioral intervention. The Eunice Kennedy Shriver National Institute of Child Health and Development data and specimen hub provided the data for this study. Included were 374 women undergoing surgery for both stress urinary incontinence and stage 2–4 pelvic organ prolapse from 2008 to 2013. All participants underwent vaginal prolapse repair and midurethral sling, and were randomized to either perioperative pelvic muscle therapy or usual care. The Pain scale, the Pelvic Floor Impact Questionnaire, the Pelvic Floor Distress Inventory, and the Patient Global Impression of Improvement were all completed by patients at baseline and repeated through month 24. The OPTIMAL trial had a primary outcome of surgical success as defined by anatomical success, but the primary outcome of this secondary analysis was a change in pain scale scores over 24 months after surgery. Three hundred seventy-four women participated in the original trial, with 368 in this secondary analysis. One hundred nine of the 368 women reported preoperative pain. Women with pelvic pain were more likely to be Hispanic, but there were no differences in surgical procedures performed, hospital stay, complications (ie, bladder injury, suture exposure, etc), or estimated blood loss in women with and without pelvic pain. Women with preoperative pain experienced greater pain at all time points, but also exhibited greater pain improvement at 24 months after surgery. Women with preoperative pain had worse baseline pelvic floor symptoms than those without pain. Although women with pain and women without pain had improvements in distress symptoms measured with the Pelvic Floor Distress Inventory, women with pain saw a greater improvement after surgery. All distress subscales improved significantly more in women with pain than women without pain. One additional interesting finding was that women randomized to sacrospinous suspension and pelvic muscle therapy had greater improvements in postoperative pain than those randomized to usual care. Notably, rates of surgical anatomic success and extent of Patient Global Impression of Improvement were not different between women with and without pain. Strengths of the study include its design as a secondary analysis of a large prospective multicenter randomized controlled trial. A substantial proportion of participants reported at least moderate pain at baseline but were not selected based on preoperative pain. Women in the trial were randomized to types of vaginal reconstructive surgery and pelvic muscle training, which allowed the authors to draw conclusions in categories of physical therapy treatments and surgeries for women with and without preoperative pain. Limitations of the study include a lack of preoperative pain data, pain diagnoses, and participant medications in the OPTIMAL trial. Furthermore, the study used no validated pain scale and was limited by OPTIMAL trial data collection intervals. Thankfully, data collected at numerous points over 24 months in some regard accounted for pain symptoms over time. The study found that, for patients with preoperative pain, significant improvement in pelvic floor symptoms and pain takes place after vaginal reconstructive surgery. Similar postoperative improvement rates were found. In addition, perioperative pelvic floor muscle training may be beneficial for patients with planned sacrospinous ligament fixation.

Rehabilitation programs for women after vaginal plastic surgery with native tissues (educational and methodological manual)

Rehabilitation programs for women after vaginal plastic surgery with native tissues (educational and methodological manual)

SAT326 Massive Adrenomyelolipomas Due To Longstanding CAH

Abstract Disclosure: Q. Aziz: None. A. Champion: None. Introduction: Congenital Adrenal Hyperplasia (CAH) is an autosomal recessive disorder caused by deficiency in adrenal corticosteroid biosynthesis. 21 Hydroxylase Deficiency is common in 90-95% of CAH cases and have a defect in converting 17 OH Progesterone to 11 deoxycortisol. Therefore, they have an increase in ACTH secretion due to the decrease negative feedback drive along with excess adrenal androgens. Adrenal myelolipoma are common in patients with CAH and the tumors are benign and lipomatous. Clinical Case: Patient is a 47 year old female with past medical history of CAH presents to the clinic for evaluation of generalized fatigue and abdominal pain. She was diagnosed with CAH- 21 hydroxylase deficiency at birth and required vaginal reconstruction surgery. She was on hydrocortisone and fludrocortisone until age 18, but thereafter stopped taking medications or seeing physicians for nearly 30 years. CT abdomen/pelvis showed large bilateral adrenal myelolipomas, right adrenal gland measuring 23.2 cm and left adrenal gland measuring 20 cm. MRI confirmed enlarged adrenal glands. Initial labs included ACTH 299, 17-OH Progesterone &amp;gt;2000, 11 deoxycorticosterone 23.6, total testosterone 160, free testosterone 30.3, DHEA-S 192, Cortisol 2.8. She was started on fludrocortisone 50 mcg and Hydrocortisone 10 mg in the morning and 5 mg in the evening and was referred to an endocrine surgeon out of state, but surgery was not offered due to concerns of medication nonadherence. She returned to clinic 6 months after presentation, she admitted to missing multiple doses of her hydrocortisone. Repeat CT Abdomen and Pelvis showed severe compression of the IVC and right lobe of the liver along with mild compression of the kidneys and pancreas. To improve adherence, she was switched to prednisone, and eventually dexamethasone 0.75mg and fludrocortisone 100mcg. She complains of fatigue but improved abdominal pain. After a period of good adherence with medication administration, she was referred to a local surgical oncologist who agreed to do bilateral adrenalectomy due to mass effect. Conclusion: CAH is a challenging chronic disease with variable penetrance in phenotype, ranging from mild hirsutism to frank adrenal insufficiency. Massive adrenomyelolipomas are thought to be ACTH driven, especially seen in undertreated and longstanding CAH. Without the 21 hydroxylase enzyme to convert 17 OH Progesterone to 11 deoxycortisol, levels of ACTH rise. While these myelolipomas are benign and can generally be monitored, surgery should be considered if the size impairs function of surrounding organs. Bilateral adrenalectomy can also be considered in patients with CAH for refractory hypertension, hyperandrogenism and virilization, Cushing syndrome, infertility, or mass effect. Presentation: Saturday, June 17, 2023

Patient experiences following prolapse surgery implementing a same-day discharge model: a prospective study.

Previous research has not evaluated patient experiences following vaginal reconstructive surgery using a same-day discharge model. The objective of this study was to describe patient experiences following major vaginal reconstructive surgery and same-day discharge. In this descriptive study, patients undergoing vaginal hysterectomy with pelvic reconstruction were preoperatively enrolled. Questionnaires detailing experience with same-day discharge, surgical recovery, and advice for prospective patients were completed. Our primary outcome was question 7 of the Surgical Satisfaction Questionnaire: Looking back, if you "had to do it all over again" would you have the surgery again? Descriptive statistics were performed, and correlations were performed with Spearman's rank test. Sixty patients were enrolled; 54 underwent surgery. Eighty-seven percent of patients completed the 12-week questionnaire. At 12weeks, 96% of patients (n = 45) would have the surgery again, and 91% (n = 42) were satisfied with the results of surgery. Twelve weeks postoperatively, the most common patient-reported complications were urinary tract infection (n = 8, 17%), catheter concerns (n = 5, 11%), and constipation (n = 5, 11%). When asked to list the best parts of their surgical experience, half of patients felt that this was the office staff or physician themselves (n = 24, 51%). When asked what advice they would provide to future patients, the most common responses included having a support person at home and taking time for recovery. In this sample of women receiving same-day discharge following vaginal hysterectomy with pelvic reconstruction, we present a unique insight into the most common patient concerns postoperatively. Rates of satisfaction and comfort were high.

Effectiveness of prophylactic pharmacological hemostatic agents for reduction of blood loss at vaginal surgery: a systematic review and meta-analysis.

The objective was to evaluate the effectiveness of pharmacological hemostatic agents in the reduction of blood loss at vaginal surgery. A systematic review of randomized control trials (RCTs) was completed. We searched PubMed (1946-2022), Embase, and CINAHL, using search terms related to vaginal hysterectomies and reconstructive surgeries combined with peri-operative use of hemostatic agents. RCTs comparing hemostatic interventions with placebo or with standard care were analyzed with the primary outcome of estimated blood loss. Secondary outcomes included peri-operative complications, length of stay, blood transfusion, and readmission. Risk of bias was assessed using the Risk of Bias 2 tool. Nine RCTs were included with a total of 903 participants. All trials were considered to have an overall low risk of bias. Meta-analysis of six RCTs (491 participants) favored the use of vasoconstrictive agent (vasopressin/ornipressin) at the surgical site for an overall effect estimate of decreased blood loss by 70ml (95% CI -125, -14ml). There was significant heterogeneity of studies with both dose and technique of vasoconstrictive agents used. Only one RCT evaluated tranexamic acid and found a benefit in the prophylactic use of intravenous tranexamic acid. Peri-operative use of vasoconstrictive agents slightly reduces bleeding in women undergoing elective vaginal surgery. Additional studies evaluating alternative pharmacological agents such as tranexamic acid may be of benefit.

Evaluation of Lower Urinary Symptoms Following Vaginal Reconstructive Surgery for Prolapse and Urinary Incontinence

Background: Urinary incontinence (UI) may be associated with symptoms of overactive bladder (OAB) that may persist after anti-incontinence surgery. Objectives: The present study was performed to evaluate the effect of prolapse and anti-incontinence reconstructive surgery in women who had the symptoms of OAB and UI at the same time. Methods: This descriptive cross-sectional study was performed on 56 women with OAB symptoms and stress UI (SUI)/urgency UI (UUI) with or without prolapse who were candidates for restorative and anti-incontinence surgery. At baseline, urinary symptoms, including urinary frequency, nocturia, SUI, and UUI, were recorded. Patients who finally underwent vaginal reconstructive surgery with anti-incontinence surgery were assessed for urinary symptoms six months after the operation. Results: A total of 28 patients underwent transobturator tape (TOT) surgery, of whom 23 patients were subjected to other anti-incontinence surgeries and 5 patients underwent restorative surgeries. There was no significant difference between the two groups (TOT and others) in terms of age, body mass index, number of deliveries, history of medical problems, and history of surgery or cesarean section. The urinary frequency and nocturia before surgery were observed in 46 (82%) and 20 (36%) patients, respectively, which were not significantly different between the two groups. Before the study, occult UI was observed in 2 patients (4%), UUI in 3 patients (5%), SUI in 18 patients (32%), and mixed UI in 33 patients (59%). Nocturia was completely improved in all 20 patients. Urinary frequency was partially or completely improved in 41 patients (89%), which was not significantly different between the two groups (P=0.051). Overall, 53 patients (95%) had partial or complete improvement in UI, which was not significantly different between the two groups (P=0.058). Both patients with occult UI and all three patients with UUI were completely improved. Sixteen out of 18 patients (89%) with SUI were completely improved and the other 2 patients were partially improved. Thirty patients (91%) with mixed UI had a complete or partial recovery that was not significantly different between the two groups (P=0.137). Conclusion: The findings of the present study showed that six months after anti-incontinence or reconstructive surgery, nocturia in all patients and urinary frequency in 89% of patients improved partially or completely. Various forms of UI partially or completely improved in 95% of patients, as well.

Standard Restrictions vs Expedited Activity After Pelvic Organ Prolapse Surgery

Restrictions on postoperative activity following pelvic organ prolapse (POP) surgery are not evidence based. Nonetheless, many pelvic surgeons place lifting and activity restrictions on patients following surgery. To evaluate whether expedited activity results in noninferior anatomic and symptomatic outcomes compared with standard activity restrictions after POP surgery. This randomized noninferiority clinical trial included patients undergoing vaginal or laparoscopic apical reconstructive surgery for POP between July 1, 2020, and October 31, 2021, at a single academic tertiary referral center in Durham, North Carolina. Anatomic outcomes were assessed by masked examiners, and subjective outcomes were assessed via validated surveys, both completed at 3 months postoperatively. Patients meeting minimum physical activity criteria with at least stage II bothersome POP were eligible. A total of 218 patients were approached, of whom 123 were randomly assigned and 107 had complete outcome data and were included in the analysis. Patients were randomly assigned to receive standard restrictions vs expedited postoperative activity instructions. The anatomic coprimary outcome was maximum anatomic POP support loss (SLmax), which is the most distal point of pelvic organ support loss according to the Pelvic Organ Prolapse Quantification System (noninferiority margin, 1.0 cm). The symptomatic coprimary outcome was the Pelvic Organ Prolapse Distress Inventory (POPDI) symptom score (noninferiority margin, 34.3 points). Differences between outcomes were assessed using linear regression models controlling for baseline SLmax and POPDI, respectively. Of 123 participants randomized, 107 had complete 3-month outcome data and were included in the analysis. Mean (SD) age was 62.8 (10.1) years. At 3 months, mean (SD) SLmax was -1.7 (1.4) cm in the expedited group and -1.5 (1.4) cm in the standard group (P = .44). After adjusting for baseline SLmax, the mean maximum support loss was 0.18 cm higher within the vaginal canal in the expedited group (95% CI, -0.68 to 0.33 cm). The coprimary outcome of POPDI score was a mean (SD) 23.7 (41.8) points in the expedited group vs 25.7 (39.3) points in the standard group (P = .80). After adjusting for baseline scores, mean POPDI scores were 5.79 points lower in the expedited group (95% CI, -20.41 to 8.84). The findings demonstrate that expedited activity after prolapse surgery results in noninferior anatomic and symptomatic prolapse outcomes. It is reasonable to instruct patients undergoing minimally invasive prolapse surgery to resume physical activities ad lib postoperatively. ClinicalTrials.gov Identifier: NCT04329715.

Methods of reduction of blood loss at vaginal surgery: A systematic review

Approximately one in ten women undergo pelvic reconstructive surgery during their lifetime, and almost one third have preoperative anemia. Knowledge of strategies for reduction of blood loss at vaginal surgery may optimize post-operative outcomes. We aimed to evaluate the effectiveness of tranexamic acid and other hemostatic agents in reduction of surgical blood loss at vaginal reconstructive surgery.

The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training.

The impact of preoperative pain on outcomes can guide counseling. The objective of this study was to compare outcomes after vaginal reconstructive surgery and pelvic muscle training between women with and without preoperative pain. This is a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial, which randomized patients to a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (pelvic floor muscle training vs usual care). Preoperative pain was defined as a response of "5" or greater on the pain scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question "Do you usually experience pain in the lower abdomen or genital area?" The OPTIMAL trial included 109 women with preoperative pain and 259 without pain. Although women with pain had worse pain scores and pelvic floor symptoms at baseline and postoperatively, they had greater improvement on pain scores (-2.3 ± 2.4 vs -0.2 ± 1.4, P < 0.001), as well as Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores. Among women with pain who underwent a sacrospinous ligament fixation, those who received pelvic floor muscle training had a greater reduction in pain compared with those in the usual care group (-3.0 ± 2.3 vs -1.3 ± 2.1, P = 0.008). Persistent or worsening pain was present at 24 months in 5 (16%) women with preoperative pain. Women with preoperative pain experience significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery. Pelvic floor muscle training perioperatively may be beneficial for select patients.

Quality of Life Following Pelvic Organ Prolapse Treatments in Women: A Systematic Review and Meta-Analysis.

Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic review aimed to investigate the impact of surgical or pessary treatment for pelvic organ prolapse (POP) on quality of life. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied. Electronic databases, including PubMed, Scopus, and Web of Science, were searched for original articles that evaluated the QoL before and after surgical interventions or pessary in pelvic organ prolapse from 1 January 2012 until 30 June 2022 with a combination of proper keywords. Included studies were categorized based on interventions, and they were tabulated to summarize the results. Results: Overall, 587 citations were retrieved. Of these, 76 articles were found eligible for final review. Overall, three categories of intervention were identified: vaginal surgeries (47 studies), abdominal surgeries (18 studies), and pessary intervention (11 studies). Almost all interventions were associated with improved quality of life. The results of the meta-analysis showed a significant association between the employment of surgical approach techniques (including vaginal and abdominal surgeries) and the quality of life (Pelvic Floor Distress Inventory (PFDI) (MD: −48.08, 95% CI: −62.34 to −33.77, p-value < 0.01), Pelvic Floor Impact Questionnaire (PFIQ) (MD: −33.41, 95% CI: −43.48 to −23.34, p < 0.01)) and sexual activity of patients with pelvic organ prolapse (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) (MD: 4.84, 95% CI: 1.75 to 7.92, p < 0.01)). Furthermore, narrative synthesis for studies investigating the effect of the pessary approach showed a positive association between the use of this instrument and improvement in the quality of life and sexual activity. Conclusions: The results of our study revealed a significant improvement in the women’s quality of life following abdominal and vaginal reconstructive surgery. The use of pessary was also associated with increased patient quality of life.

A New Insight Into Ectopic Sebaceous Glands in the Vagina: A Result of Surgery?

Abstract Introduction/Objective Ectopic sebaceous glands with or without hair follicles are well documented in a variety of sites including the vulva, cervix, esophagus, and male genitalia. Ectopic sebaceous glands in the vagina, however, are extremely rare, with only 2 case reports and a third case described in a journal correspondence letter in the English literature. Methods/Case Report We present a 39-year-old patient with Laurence-Moon-Biedl syndrome with pseudotumor cerebri, retinitis pigmentosa/macular degeneration, chronic kidney disease status post renal transplant, obesity, diabetes insipidus, and a urethrovaginal fistula and hypoplastic vagina status post repair and vaginoplasty at age 3 months. High grade squamous intraepithelial lesion on a cervicovaginal Pap test prompted colposcopy, during which a confluent plaque non-staining with Lugol’s solution was noted on the right vaginal sidewall extending from the introitus to 4 cm distal to the cervix. Biopsy of this area revealed hyper- and parakeratosis along with sebaceous glands and hair follicles in the subepithelial stroma. Two theories are proposed in the literature regarding the origin of vaginal ectopic sebaceous glands/cutaneous adnexal structures. The first is a developmental anomaly with aberrant differentiation in-utero, as the lower two thirds of the vagina is normally endodermal in origin and the upper one third is derived from mesoderm, while cutaneous adnexal structures are ectodermal in origin. The second postulates sebaceous glands in the vagina arise from a metaplastic process after prolonged irritation or inflammation. We add a third possibility in this patient, that vaginal plastic surgery performed at 3 months of age involved tissue re- arrangement or grafting which introduced ectodermal structures to the vagina. The patient’s vaginal surgical records were not available for review. Results (if a Case Study enter NA) NA. Conclusion We add a fourth case of ectopic cutaneous adnexal structures in the vagina in a patient with Laurence-Moon-Biedl syndrome to the literature. The origin of these structures may have resulted from vaginal surgery as an infant rather than from a developmental anomaly or metaplasia.

Preoperative Tamsulosin to Prevent Postoperative Urinary Retention after Pelvic Floor Repair Surgery

<h3>Study Objective</h3> The purpose of the study is to evaluate the effect of preoperative Tamsulosin on postoperative urinary retention (POUR) in patients undergoing surgery for pelvic organ prolapse. <h3>Design</h3> A prospective randomized control trial. <h3>Setting</h3> Patients enrolled in the outpatient clinic setting. Medication given in the preoperative area, the day of surgery. Voiding trial was performed in the post-anesthesia recovery unit (PACU). <h3>Patients or Participants</h3> 100 patients were enrolled with 50 in each arm, randomly assigned. Patients diagnosed with pelvic organ prolapse undergoing vaginal or laparoscopic reconstructive pelvic surgery with or without mid-urethral sling. <h3>Interventions</h3> Oral Tamsulosin 0.4mg given 30-90 minutes before the procedure. Active voiding trial was performed within 4 hours of patients arriving to the PACU. <h3>Measurements and Main Results</h3> 48 patients enrolled in the control group and 47 patients in the study group. When comparing demographics, there were no statistically significant differences between the groups except for preoperative uterine prolapse <i>(p<0.05).</i> For the primary outcome, there was no statistically significant difference in incidence of POUR between the 2 groups <i>(p=0.73).</i> A total of 36 patients had POUR; 17 (36.2%) in the study group and 19 (39.6%) in the placebo group. A multivariate cox regression analysis determined that the study group had a hazard risk of 1.1 [95% CI 0.47-2.59] but was not statistically significant <i>(p=0.81).</i> Preoperative uterine prolapse also had an increase hazard risk of 1.25 [95% CI 0.52-3.04] but also failed to meet statistical significance <i>(p=0.62).</i> Postoperative narcotic use <i>(p=1.0)</i> and increased length of surgery <i>(p=0.51)</i> had no increase in POUR. <h3>Conclusion</h3> In this study, the incidence of POUR was not significantly decreased after a single preoperative dose of Tamsulosin. Receiving Tamsulosin with preoperative uterine prolapse had an increased hazard risk for POUR but was not statistically significant. At this time, we do not recommend a single dose of tamsulosin to decrease POUR after prolapse surgery.

PSUN247 Unique Presentation of MODY Type 5

Abstract A 46-year-old female with a past medical history significant for a blind vaginal birth defect that required vaginal reconstructive surgery with a partial hysterectomy at 15 years old and Type 2 Diabetes diagnosed at 44 years old. The patient was started on Sitagliptin, metformin 500 mg BID, and glimepiride 2 mg, but she remained poorly controlled with A1C 12.5%. Liver enzymes were elevated with the following values on the liver panel: AST 63 U/L Alt113 U/L bilirubin total 1.0 U/L direct bilirubin 0.3 U/L Alkaline phosphatase 642 U/L. Abdominal ultrasound and serology for chronic liver disease were unremarkable; enhanced MRI of the abdomen showed no abnormalities in the liver and pancreas. CT-guided liver biopsy was performed and pathology revealed diabetic hepatosclerosis. Ultimately, the patient was referred for endocrinology evaluation for poorly controlled diabetes mellites. Blood work was negative for GAD antibodies 65 and anti-pancreatic islet cell antibodies. C peptide level was within normal limits. The patient was not compliant with medications; her A1C continues to range between 11.5 and 8.5 so she was started on subcutaneous insulin. A few years later, the patient presented to the ED for generalized weakness, anorexia, and unintentional weight loss of approximately 40 pounds with a BMI of 17 kg/m2. Bloodwork revealed glucose was 222 mg/dl, and glycated hemoglobin (A1C) was 15.4%, with no acute metabolic disorder (no ketosis). Biochemical analysis reported triglycerides of 174 mg/dL, total cholesterol of 280 mg/dL, HDL of 82 mg/dL, aspartate aminotransferase of 75 U/L, alanine aminotransferase of 117 U/L. alkaline phosphatases 190U/L, Potassium 3.1mEq/L, and magnesium 1.3mEq/L Her electrolytes failed to correct despite adequate replacement; hence nephrology evaluation was warranted. As a result, 24h urine collection was obtained and revealed a Gitelman pattern with salt wasting, K+ wasting, Mg2+ wasting, and no calcinuria. This raised suspicion for MODY type 5. An enhanced MRI of the abdomen revealed her pancreas was missing the distal body and tail as well as bilateral cystic kidney disease. Genetic testing was pursued and demonstrated mutations in the hepatic nuclear factor 1B (HNF1B) gene which confirmed the MODY type 5 diagnosis. The patient was discharged on 11 units of insulin degludec at bedtime in addition to insulin aspart 2 units TID; her A1c improved to 8.3% on her most recent follow-up. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Rotational labial and inferior pudendal artery based inner thigh flaps for vaginal defect after reconstructive surgery

For vaginal reconstructive surgery, the vaginal defect sometimes cannot be closed with primary intention due to poor tissue quality or loss of the vaginal wall. To cover the defect, plastic surgeons may be consulted with regard to a tissue advancement flap, a very complex procedure, and urologists may not feel familiar with it or comfortable with carrying it out. The rotational labial and inferior pudendal artery based inner thigh flap, devised by Professor Shlomo Raz, is a simple and useful procedure which urologists can perform with a short learning curve. Therefore, this article aims to demonstrate the surgical technique involved in this flap which can be widely used as an adjunct to any vaginal reconstructive procedures.

Are Formal Voiding Trials Necessary After Posterior Compartment Reconstructive Surgery?

Posterior compartment surgery is considered a risk factor for postoperative urinary retention because of the impact of postoperative pain on the pelvic floor; however, few studies have examined the association between posterior compartment reconstructive surgery and urinary retention. The aim of the study was to compare rates of urinary retention in patients undergoing vaginal reconstructive surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment). In this retrospective cohort study, we evaluated patients who underwent surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment) from January 2015 to November 2020. Our primary outcome was rate of postoperative urinary retention, defined as a failed voiding trial before discharge. Secondary outcome was days of catheterization. Multivariable logistic regression was performed to assess variables associated with a failed voiding trial. Of 362 patients, 141 (39.0%) underwent surgery in the posterior compartment only and 221 (61.0%) underwent vaginal apical and/or anterior compartment surgical procedures. Rate of retention was significantly lower in the posterior compartment only group (9.9% vs 41.6%, P < 0.001). The median numbers of days of catheterization were significantly fewer in the posterior compartment only group (0 [0,0] vs 0 [0,3], P < 0.001). In multivariable logistic regression, posterior compartment only surgery was associated with passing the voiding trial (odds ratio, 6.0; 95% confidence interval, 2.97-12.03). Rates of postoperative urinary retention after surgery in the posterior compartment are low, and these patients may not require formal voiding trials after surgery.

Pass or Fail? Postoperative Active Voiding Trials in an Enhanced Recovery Program.

Pelvic reconstructive surgery is often associated with transient postoperative voiding dysfunction. This study aimed to compare postoperative active voiding trial (AVT) outcomes before and after implementation of an enhanced recovery program (ERP) for women undergoing pelvic reconstructive surgery. In addition, risk factors for postoperative urinary retention were identified. We retrospectively identified patients undergoing inpatient vaginal or robotic pelvic reconstructive surgery before and after implementation of an ERP at our institution. Demographics, operative and postoperative details, and AVT outcomes were collected. Primary outcome was AVT failure. Variables associated with increased risk of AVT failure were identified using multivariate analysis. Three hundred seventeen patients were included-75 pre-ERP and 242 ERP. There was no difference in AVT failures between pre-ERP and ERP groups (21.3% vs 21.9%, P = 0.92). The AVT failures were highest among those with abnormal preoperative postvoid residual volume (PVR ≥100 mL, 25.9% vs 12.2%, P = 0.01) and those who underwent an incontinence procedure (midurethral sling or Kelly plication, 30.4% vs 16.9%, P = 0.01). Compared with a reference procedure (total vaginal hysterectomy [TVH]), the following procedures were associated with statistically significant higher odds ratios (ORs) of AVT failure: TVH with incontinence procedure (OR, 15.0; confidence interval [CI], 4.58-48.9; P < 0.001), TVH with anterior repair (OR, 4.98; CI, 1.93-12.9; P = 0.001), and robotic sacrocolpopexy (OR, 3.6; CI, 1.18-11.2; P = 0.02). Postoperative AVT failure incidence did not differ pre- and post-ERP intervention. Abnormal preoperative PVR was associated with failed postoperative voiding trial. Concomitant incontinence procedures and/or anterior colporrhaphy were associated with increased incidence of voiding trial failure regardless of ERP cohort.

PD44-06 PUDENDAL BLOCK ANALGESIA WITH VAGINAL SURGERY: A RANDOMIZED, DOUBLE-BLIND, PLACEBO CONTROLLED TRIAL

You have accessJournal of UrologyCME1 May 2022PD44-06 PUDENDAL BLOCK ANALGESIA WITH VAGINAL SURGERY: A RANDOMIZED, DOUBLE-BLIND, PLACEBO CONTROLLED TRIAL Emily Slopnick, Graham Chapman, David D. Sheyn, Sarah Sears, Megan Abrams, Kasey M. Roberts, Robert Pollard, and Jeffrey Mangel Emily SlopnickEmily Slopnick More articles by this author , Graham ChapmanGraham Chapman More articles by this author , David D. SheynDavid D. Sheyn More articles by this author , Sarah SearsSarah Sears More articles by this author , Megan AbramsMegan Abrams More articles by this author , Kasey M. RobertsKasey M. Roberts More articles by this author , Robert PollardRobert Pollard More articles by this author , and Jeffrey MangelJeffrey Mangel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002605.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Effective opioid-sparing postoperative analgesia often requires a multimodal approach, which may include regional nerve blocks. The objective of this randomized controlled trial is to determine whether a pudendal nerve block is associated with improved postoperative pain control and decreased opioid consumption compared to a sham injection at the time of vaginal pelvic reconstructive surgery (PRS). METHODS: In this randomized, double-blind, placebo controlled trial, we enrolled women undergoing benign vaginal PRS at a single academic institution. Exclusion criteria included patients with a diagnosis of chronic pelvic pain, inability to receive non-narcotic analgesia, or any concurrent abdominal procedure. Patients were randomized to receive a transvaginal pudendal nerve block (9mL 0.25% bupivacaine + 1mL 40mg/mL triamcinolone) or a sham injection (10mL normal saline) at the conclusion of surgery. The injection syringe was wrapped by pharmacy to blind the surgeon. Postoperatively, all patients received routine care. Primary endpoints were visual analog pain scores (VAS) and postoperative opioid requirement, measured in the post-anesthesia recovery unit (PACU) and on post-operative days (POD) 1 and 4. A power calculation determined 60 patients were required to show a mean difference of 20mm on a 100mm VAS. Opioid administration was standardized as morphine milligram equivalents (MME), and VAS scores were compared with Wilcoxon-Mann-Whitney analysis. RESULTS: We randomized 71 patients: 36 pudendal block and 35 sham injection. The study groups were well matched with no differences in baseline characteristics or type of surgery performed. Pelvic organ prolapse repairs were the most common procedures (n=63, 87.5%). There was no difference in anesthetic dose or operative time between groups. Pain scores were equivalent between groups in the PACU (mean VAS 53.1 block vs 56.4 sham, p=0.517) and on POD 4 (mean VAS 26.7 block vs 35.5 sham, p=0.131). On POD 1, the intervention group did report less pain than the sham group (mean VAS 29.2 vs 42.5, p=0.047). Patients who received a pudendal block took fewer opioid medications than those in the sham group at all time points, but this difference did not meet statistical significance (PACU 5 vs 7.8 MME, POD1 7.5 vs 11.25 MME, POD4 7.5 vs 21.25 MME, all p>0.05). CONCLUSIONS: Pudendal nerve block resulted in decreased pain reported in the immediate postoperative period and less opioid use, though not statistically significant. Pudendal block may be an additional tool for non-narcotic perioperative analgesia with vaginal PRS. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e710 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily Slopnick More articles by this author Graham Chapman More articles by this author David D. Sheyn More articles by this author Sarah Sears More articles by this author Megan Abrams More articles by this author Kasey M. Roberts More articles by this author Robert Pollard More articles by this author Jeffrey Mangel More articles by this author Expand All Advertisement PDF DownloadLoading ...