Colporrhaphy Research Articles

Pattern of suture use for pelvic organ prolapse surgery

Permanent and delayed suture types may be similar in anatomic outcomes after surgical correction of pelvic organ prolapse; however, surgeon preference could vary. A survey investigating the practice patterns of suture use in female pelvic reconstructive surgery was conducted. An IRB-approved survey was distributed through the Society of Gynecologic Surgeons by a link via email to 278 members and shared on Twitter using #gynecologic surgery, @FPMRS, @Gyn Surgery, and @iugaoffice. Surgeon demographics and suture preference for various pelvic organ prolapse surgeries was queried with 36 questions. Responses were analyzed with descriptive statistics. We received 110/278 (40%) responses from surgeons including 86% urogynecologists, 6% Ob/Gyn, and 8% other. 47% were male, and 52% female. 20% of respondents were 0-4 years in practice, 21% were 5-9 years, 15% 10-15, years 12% 16-20 years, and 33% were >20 years in practice. Most respondents were academically affiliated (73%), whereas 10% were in hospital practice and 15% were in private practice. Most respondents perform >50 prolapse surgeries per year (76%) and 6% perform <20. The majority (99%) were Ob Gyn trained vs Urology trained (1%) and 80% are board certified in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). The types of sutures used varied between the different surgeries (Table 1). Some surgeries had a strong suture preference among surgeons, with 88% of surgeons preferring to use permanent sutures for sacral attachment during sacrocolpopexy, and 56% using delayed absorbable for the vaginal attachment. Delayed absorbable suture was the most common preference for uterosacral ligament suspension (USLS) 54%, and sacrospinous ligament fixation (SSLF) 54%. There was greater disparity in responses regarding suture preference for anterior colporrhaphy, posterior colporrhaphy, and colpocleisis; however, most surgeons reported a preference for absorbable (38-46%) or delayed absorbable suture (32-49%). In this group of predominantly gynecology trained FPMRS surgeons in SGS, there was a strong preference for permanent suture for the sacral attachment for sacrocolpopexy and delayed absorbable for the vaginal attachment. Delayed absorbable suture was also the preference for apical sutures for USLS and SSLF. We acknowledge limitations of small sample size; however, we did query highly trained, high volume surgeons. Our next step is to expand this survey to capture more respondents.

Laparoscopic management of persistent vaginal discharge remote from sacrocolpopexy

Demonstrate surgical management of sinus tract formation from infected suture material. Sacrocolpopexy is considered the "gold standard" by many for the management of advanced pelvic organ prolapse. Adverse outcomes, such as anatomic failure and mesh or suture exposure, have been shown to occur over increased length of time from the index surgery. Given permanent foreign body placement with this reconstructive technique, inflammatory reaction due to infection may result in complication. We present a 60-year-old gravida 4 para 4 with a two-year history of persistent vaginal discharge. Her surgical history is notable for laparoscopic hysterectomy, sacrocolpopexy, midurethral sling, and posterior colporrhaphy 12 years ago, as well as ventral and right inguinal hernias repaired with abdominal mesh 2 years ago. The patient did not have recurrence of prolapse on exam. This case demonstrates management of sinus tract formation from an inflammatory response to infected tissue from permanent polyester braided suture material. The case was begun with intraabdominal survey. The peritonealized mesh was identified, and the distal end was noted to be edematous. Culture results showed a polymicrobial infection. Dissection was performed over the apical mesh. Suture material and involved mesh were identified and resected. Minimal tissue integration into the macropores of the mesh was observed. A vaginotomy was created due to the sinus tract and was repaired with Monocryl suture after bladder dissection. The overlying peritoneum was dissected superiorly, and the mesh was excised until healthy tissue with mesh integration was identified. The peritoneum was reapproximated using barbed suture, and the patient was discharged with a 7-day course of antibiotics. To avoid infectious complications, surgeons may consider avoiding braided polyester suture for vaginal mesh attachment when performing sacrocolpopexy.

Infected pelvic hematoma following vaginal hysterectomy with uterosacral ligament suspension for treatment of apical prolapse

ObjectiveVaginal hysterectomy with uterosacral ligament suspension (VUSLS) is a common procedure for apical prolapse repair. Data regarding pelvic hematoma following this procedure is scarce. The aim of this study was to describe the occurrence of infected and non-infected pelvic hematoma in women following VUSLS and to assess for specific risk factors for infection. MethodsWe performed a retrospective cohort study, including all women who underwent VUSLS for treatment of apical prolapse between 2010 and 2020. Patients with and without pelvic hematoma by ultrasound were compared. A subgroup analysis compared patients with infected vs non infected hematomas. ResultsDuring the study period, 316 women underwent VUSLS for treatment of apical prolapse. Sixty-six (20.9%) were diagnosed with a pelvic hematoma, and in seventeen (5.4%) women the hematoma became infected. The majority (76%) of pelvic hematomas were located above the vaginal cuff.Women in the hematoma group had increased rates of hypothyroidism and concomitant anterior colporrhaphy. However, following multivariate analysis, these differences were no longer significant.Subgroup analysis comparing women with infected versus non-infected pelvic hematoma was performed. No differences were noted with respect to surgical outcomes (clinical, anatomical, or composite). Women with infected hematoma had higher rates of posterior colporrhaphy during surgery (33.3% vs 9.5%, p = 0.039). This difference remained significant following multivariate analysis (aOR = 8.87, CI 1.1–73.0). ConclusionPelvic hematoma following VUSLS is common as opposed to infected pelvic hematoma which seldom occurs. Concomitant posterior colporrhaphy was associated with infection.

A0989 - Anterior colporrhaphy and sacrospinous hysteropexy in women with pelvic organ prolapse: Urodynamic findings and functional outcomes

A0989 - Anterior colporrhaphy and sacrospinous hysteropexy in women with pelvic organ prolapse: Urodynamic findings and functional outcomes

Etiology, staging, and management of cystocele

A cystocele is usually found to protrude the urinary bladder through the vaginal wall. Various causes have been reported in the literature for the pathogenesis and development of cystocele. These can cumulatively lead to a remarkable weakness in the muscular and connective tissue layers related to the urinary bladder and anterior vaginal wall. The present study discusses the etiology, staging, and management of patients with cystocele. Evidence indicates that a defect within the pelvic-floor supporting system can significantly lead to the development of cystocele. Parity, increasing age, and obesity are the main associated risk factors for developing these events. Staging is important to decide the most suitable treatment plan, which might be conservative or surgical. Some patients do not require any management approach, being asymptomatic, and refuse the current treatment modalities. Surgery has been associated with enhanced outcomes and can be conducted via two different approaches, including anterior colporrhaphy and sacral colpopexy.

Effect of gelatin methacryloyl hydrogel on healing of the guinea pig vaginal wall with or without mesh augmentation.

The aims of this study were to evaluate the effectiveness of gelatin methacryloyl as an adjunct to anterior vaginal wall injury with or without vaginal mesh compared with traditional repair with suture. Virginal cycling Hartley strain guinea pigs (n= 60) were randomized to undergo surgical injury and repair using either polyglactin 910 suture or gelatin methacryloyl for epithelium re-approximation or anterior colporrhaphy with mesh augmentation using either polyglactin 910 suture or gelatin methacryloyl for mesh fixation and epithelium re-approximation. Noninjured controls (n= 5) were also evaluated. After 4 days, 4 weeks, or 3 months, tissues were analyzed by hematoxylin & eosin in addition to immunolabeling for macrophages, leukocytes, smooth muscle, and fibroblasts. Surgical injury repaired with suture was associated with increased inflammation and vessel density compared with gelatin methacryloyl. Vimentin and α-smooth muscle actin expression were increased with gelatin methacryloyl at 4 days (p= 0.0026, p= 0.0272). There were no differences in changes in smooth muscle or overall histomorphology after 3months between the two closure techniques. Mesh repair with suture was also associated with increased inflammation and vessel density relative to gelatin methacryloyl. Quantification of collagen content by picrosirius red staining revealed increased thick collagen fibers throughout the implanted mesh with gelatin methacryloyl compared with suture at 4 weeks (0.62 ± 0.01 μm2 vs 0.55 ± 0.01, p = 0.018). Even at the long-term time point of 3 months, mesh repair with suture resulted in a profibrotic encapsulation of the mesh fibers, which was minimal with gelatin methacryloyl. Smooth muscle density was suppressed after mesh implantation returning to baseline levels at 3 months regardless of fixation with suture or gelatin methacryloyl. These results suggest that gelatin methacryloyl might be a safe alternative to suture for epithelium re-approximation and anchoring of prolapse meshes to the vagina and may improve chronic inflammation in the vaginal wall associated with mesh complications.

Obstructed defecation syndrome in the first week after pelvic reconstructive surgery.

Research shows that patients are concerned about postoperative bowel function after pelvic reconstructive surgery. The objectives of this study were to estimate the proportion of patients with obstructed defecation syndrome (ODS), a subtype of constipation, in the week after surgery, to identify associated patient-level and perioperative characteristics and the associated bother. Women completed a preoperative and postoperative ODS questionnaire and postoperative bowel diary. Characteristics of women with and without postoperative ODS were compared. Chi-squared or Fisher's exact tests compared categorical variables. Student's t test or Wilcoxon rank-sum tests compared continuous variables. Multivariate logistic regression was assessed for independent effects. Wilcoxon rank-sum tests compared the groups with regard to bother. Spearman correlation coefficients described the relationship among bother, postoperative ODS score, and bowel diary variables. Of the 186 participants enrolled, 165 completed the postoperative ODS questionnaire. Of these, 39 women (23.6%, 95% CI 17.2-30.1) had postoperative ODS. Postoperative ODS was significantly associated with preoperative ODS (p < 0.001), posterior colporrhaphy (p = 0.03), surgery type (p = 0.01), and longer duration of surgery (p = 0.03). Using multivariate logistic regression controlling for age, only preoperative ODS was significantly associated with postoperative ODS (OR 2.68, 95% CI 1.73-4.17). Women with postoperative ODS reported more bother with their defecatory symptoms (p < 0.001). The degree of bother was significantly associated with postoperative ODS score (p < 0.001). Using a validated disease-specific questionnaire to identify ODS, this complication was identified in 23.6% of patients in the week after pelvic reconstructive surgery. Preoperative ODS was a significant and important risk factor for this complication.

Role of Anterior Colporrhaphy in Post Void Residual Urine Volume and Stress Urinary Incontinence: A Prospective Interventional Study

Introduction: Pelvic floor disorders are quite debilitating for middle aged and elderly women. Post Void Residual (PVR) urine volume is a key marker for the efficacy of emptying of bladder. Both, preoperative and postoperative assessment of PVR volume helps to know about the voiding dysfunction and help to detect Stress Urinary Incontinence (SUI). There is a paucity of data available regarding postoperative outcome assessment of surgical intervention in terms of PVR urine volume. Aim: To identify the risk factors for elevated PVR and to evaluate the rate of resolution of elevated PVR in patients undergoing vaginal hysterectomy with anterior colporrhaphy for Pelvic Organ Prolapse (POP). Materials and Methods: A prospective interventional study was conducted at Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Delhi from June 2019 to June 2021. A total of 50 patients with POP meeting the inclusion criteria were enrolled. Preoperative grade of prolapse, SUI and PVR urine volume was assessed. All patients enrolled in study, underwent vaginal hysterectomy with anterior colporrhaphy. Postoperative PVR urine volume and de novo SUI and occult stress urinary incontinence (OSUI) was assessed. Data was analysed using Statistical Package for the Social Sciences (SPSS) version 21.0. The p-value &lt;0.05 was considered significant. Qualitative variables were analysed using Fischer's exact test. Results: Preoperative PVR (≥50 mL) was seen in 28 (56%) women. Advancing age (p-value 0.043) higher Body Mass Index (BMI) (p-value=0.033) higher POP (p-value=0.003) and higher degree of cystocele (p-value&lt;0.001) staging were significantly associated with elevated preoperative PVR. In this study, only 22% of patients (11/50) had preoperative SUI and 12% (6/50) had preoperative OSUI. In this study amongst the six patients with preoperative OSUI, 100% had significant preoperative PVR. None of the patients with preoperative SUI and preoperative OSUI had postoperative persistent SUI or de novo SUI after undergoing anterior colporrhaphy with vaginal hysterectomy (p-value &lt;0.001). Conclusion: PVR urine volume is increased with degree of prolapse. Raised PVR is also associated with OSUI, which is usually seen in patients with advanced prolapse and cystocele. Vaginal hysterectomy with anterior colporrhaphy significantly reduced postoperative PVR and SUI.

An Unusual Complication of Gluteal Fistula after Sacrospinous Ligament Suspension: A Case Report

Background: Sacrospinous ligament suspension (SSLS), also referred to as sacrospinous ligament fixation, is a well-established transvaginal procedure performed to treat apical prolapse. Serious complications are uncommon following SSLS, and mild infectious complications, such as cystitis, are most common. In this report, we present an uncommon case of gluteal fistula as a complication of this procedure. Case: A multiparous 48-year-old with a history of vaginal hysterectomy with bilateral salpingectomy, anterior and posterior colporrhaphy, and sacrospinous ligament suspension presented one year later with multiple emergency department visits for gluteal abscesses and continuous right gluteal drainage. MRI confirmed a gluteal fistula extending from the sacrum to the right gluteal fold and right piriformis muscle, thought to be caused by retained suture. The patient subsequently underwent an exam under anesthesia in which the reproduction of the vaginal dissection performed to place the SSLS sutures and probing of the fistula failed to expose any suture. The fistula was copiously irrigated with antibiotic solution, and on a 2-week postoperative visit, the fistula was noted to be completely healed. Conclusion: This is a rare case of gluteal fistula as a complication of SSLS procedure. In this case, the suspected retained suture causing the fistula was not identified; however, the fistula was still able to heal

Роль пектопексии в коррекции цистоцеле

Objective. To study and compare the long-term outcomes of surgical correction of cystocele with and without correction of apical prolapse by pectopexy. Design. A prospective study. Patients and methods. A total of 60 patients with cystocele stage 2 or more and apical prolapse stage 1 according to POP-Q (Pelvic Organ Prolapse Quantification System) were examined; 30 patients underwent classical anterior colpoperineorrhaphy and other 30 – combined surgeries, including anterior colporrhaphy and pectopexy. The long-term outcomes of treatment were assessed after 24 months. De novo prolapse stage 2 or more according to POP-Q was considered as prolapse recurrence. Results. The use of pectopexy in the complex surgical treatment of anterior vaginal wall prolapse combined with early stages of apical prolapse (which is not the leading point of prolapse) significantly improved long-term outcomes: 24 months after surgical treatment, cystocele stage 1 was registered only in 13.3% of cases, and 93.3% of patients had no apical prolapse. In the group of patients without pectopexy, progression of apical prolapse to stage 2 was observed in 50% of patients after 24 months. Conclusion. When planning the surgical correction of cystocele, the presence or absence of “hidden” early defects of apical support should be considered. Pectopexy in the correction of apical prolapse combined with cystocele is effective, safe, and pathogenetically sound. Its use improves the long-term outcomes of cystocele treatment and reduces the probability of recurrence. Key words: apical prolapse, long-term treatment outcomes, anterior vaginal wall prolapse, pectopexy, surgical correction, cystocele

Assessment of Safety of Vaginal Repair of Pelvic Organ Prolapse in Elderly at Birat Medical College Teaching Hospital, Nepal

Background: Pelvic organ prolapse in elder women causes sufficient morbidity and decreased quality of life. Despite age related comorbidities and decreased physiological capabilities, elder women with pelvic organ prolapse may be benefitted by surgical repair via vaginal route.The purpose of this study is to evaluate the safety of vaginal repair of pelvic organ prolapse in women of age 60 years or older.&#x0D; Materials and Methods: This hospital based analytical study was carried out in Birat Medical College Teaching Hospital from September 2020 to September 2021. Fifty-four patients aged 60 years or older with third and fourth degree pelvic organ prolapse were recruited for the study. Necessary information was obtained by self-structured questionnaire and entered into Microsoft Excel. Data was analyzed by SPSS version 22.&#x0D; Results: Fifty-four women with third or fourth degree prolapse with cystocele and rectocele underwent vaginal hysterectomy with anterior colporrhaphy with posterior colpoperineorrhaphy. No organ injury occurred during operation. There was no mortality or severe intraoperative or postoperative complications.&#x0D; Conclusion: Vaginal hysterectomy with pelvic floor repair for pelvic organ prolapse in women of 60 years or older is safe.

Complications and Success Rate in Women Undergoing Burch Colposuspension for Urinary Stress Incontinence

Our goal was to study the success rates and peri-operative and post operative complications of Burch colposuspension in women having urinary stress incontinence. The study was performed in the department of gynaecology and obstetrics, MTI Hayatabad Medical Complex, MTI Lady Reading Hospital and a private set in Peshawar. Peri and postoperative outcomes were reviewed in 54 patients who underwent Burch Colposuspension from 2012 to 2017. All operations were performed by a single experienced surgeon and patients were followed post procedure for 18-24 months. Prior to the procedure, urodynamic studies were performed on 34 patients, while others showed signs of pure stress incontinence, so they did not require urodynamic studies. Urodynamics of 28 women showed genuine stress incontinence while six showed mixed stress incontinence. 10 patients underwent additional procedures along with Burch Colposuspension, mostly posterior colporrhaphy in 6 patients. The complication rate was relatively low, with 14.8% of patients experiencing voiding difficulties and 11% experiencing Denovo detrusor instability. Burch Colposuspension is a safe surgical treatment for genuine stress incontinence.

Body Image, Sexual Function, and Sexual Satisfaction Among Couples Before and After Gynecologic Cosmetic Surgery.

Objective: This study aimed to compare women’s body image, sexual function and satisfaction before and after gynecologic cosmetic surgery. The study also aimed to assess women husband’s sexual satisfaction. Materials and methods: This was a pretest-posttest study. A sample of 50 women attending the pelvic floor clinic of Tehran University of Medical Sciences for gynecologic cosmetic surgery was entered into the study. Surgeries included labiaplasty, clitoral hoodectomy, vaginoplasty, vaginal rejuvenation, anterior and posterior colporrhaphy, perineoplasty, and perineorrhaphy. Women were assessed for the Body Image Quality of Life Inventory (BIQLI), the Larson Sexual Satisfaction Questionnaire (LSSQ-F), and Female Sexual Function Inventory (FSFI-6) at two points in time: baseline (one week before surgery) and 3 months after surgery. Similarly, the male partners were assed for sexual satisfaction using the Larson Sexual Satisfaction Questionnaire (LSSQ-M). To analyze the data paired samples t-test was applied. Results: The mean (SD) age of women was 43.36 (8.6) years and the mean (SD) duration of marriage was 22.18 (9.7) years. Ninety-four percent had history of vaginal delivery and 58.7 percent attend surgery due to husband’s sexual dissatisfaction. The results showed that women’s body image, sexual function and couples’ sexual satisfaction improved significantly after gynecologic cosmetic surgery (p ≤ 0.001). Conclusion: The findings suggest that female genital cosmetic surgery improved the body image and sexual function of women and sexual satisfaction in couples that might lead to a more pleasurable and healthier marital relationship.

Risk factors of lower urinary tract injury with laparoscopic sacrocolpopexy

BACKGROUNDLower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy.OBJECTIVEThe primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy.STUDY DESIGNThis was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios.RESULTSA total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m2 (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48–160.38; P=.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05–23.19; P=.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21–8227; P=.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury.CONCLUSIONAlthough lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.

Outcomes of vaginal hysterectomy combined with anterior and posterior colporrhaphy for pelvic organ prolapse: a single center retrospective study.

ObjectiveTo evaluate the efficacy of vaginal hysterectomy combined with anterior and posterior colporrhaphy (VH APR) for the management of pelvic organ prolapse (POP).MethodsA total of 610 patients with POP who underwent VH APR from January 2010 to June 2019 at Asan Medical Center were included in this study. We analyzed the patient characteristics and surgical outcomes. In addition, we compared the POP quantification system (POP-Q) pre- and postoperatively at 2 weeks, 3 months, and 1 year, and analyzed the risk factors for recurrence.ResultsThe mean age of the patients was 65.5±7.6 years. The most common preoperative POP-Q stage was stage 2 (60.8%), followed by stage 3 (35.9%). Complications were identified during surgery in 1.6% of the patients. The most common postoperative complication (6.4%) was voiding difficulty. All POP-Q scores significantly decreased at 1 year after surgery (P<0.0001). The recurrence rate was 9.6%, and most recurrences (77.5%) occurred in the anterior compartment. An advanced stage of preoperative POP was a risk factor for recurrence (stage 3 or 4 vs. stage 1 or 2; odds ratio [OR], 5.337, 95% confidence interval [CI], 2.58–11.036, P<0.0001). Only two patients underwent surgical correction for POP recurrence, and most of the remaining patients did not undergo further treatment for prolapse.ConclusionVH APR is a safe and effective surgical procedure for POP, with a low recurrence rate. In addition, advanced preoperative stage was the only risk factor for recurrent POP.

The role of hydrodissection in native tissue repair of anterior vaginal wall defects

A variety of surgical techniques are available for vaginal prolapse repair, indicating a lack of consensus. A debate regarding the utility of hydrodissection for splitting the surgical plane of the vaginal wall exists. The aim of this study is to evaluate the impact of hydrodissection in anterior colporrhaphy (AC). Patients undergoing primary AC were randomly assigned to an approach with (study group) versus without (control group) hydrodissection. Five surgeons performed both techniques, and the trimmed vaginal tissue was retrieved for histological analysis. Two pathologists, blinded to the surgical approach, evaluated the presence of a loose connective tissue at the surgical dissection plane (controversially deemed 'fascia', as explained in this article). In addition, we compared the operative time, pain score and haemoglobin levels. After statistical analysis, data were presented using percentile, and statistical significance was tested using the χ2 and Fisher's exact tests. Forty-six patients underwent primary elective AC, with 23 patients in each, the study and control groups. The groups were comparable regarding age (study group 60.33 ± 11.95 years and control group 59.86 ± 12.04, P = 0.90), menopausal status (study group 17 (73.9%) and control group 15 (68.2%), P = 0.67) and other characteristics. We found no difference in sample characteristics between the two groups. Connective tissue was found in only 13.6% (n = 3) of patients after hydrodissection and in 27.3% (n = 6) of patients without hydrodissection (P = 0.46). The hydrodissection group had significantly less bleeding than the control group (ΔHB 0.66 ± 0.66 vs 1.21 ± 0.84, P = 0.05). After hydrodissection, less bleeding was noted without compromise the surgical planes.

“I Felt Something Coming Down Below”: A Case of POP

Pelvic floor disorders, which includes pelvic organ prolapse (POP), have shown an increasing prevalence among women worldwide. (Wu 2014) It is perceived as embarrassment and affect the women’s quality of life. A 68-year-old housewife, Para 3, complained of a 50-cent coin size lump coming down from her vagina since 2019, which could be reduced back manually inside the vagina. The symptom exacerbated by straining and carrying heavy objects. Ignoring the symptom, causing the lump to increase in size and protruded out from her vagina for the past 2 months. She had 3 SVD with maximum birth weight of 3.75kg and a prolonged second stage of labour in her second pregnancy. She was not aware and never practiced pelvic floor exercise nor taken any HRT. There were no urinary symptoms nor constipation. Her BMI is 25.2kg/m2. Abdominal examination was unremarkable. On speculum examination, vagina was atrophic and third degree uterine prolapse was evident. She was arranged to have Vaginal hysterectomy, anterior colporrhaphy and sacrospinous fixation done. The positive risk factors in this case are multiparity, menopausal status, a history of prolonged labor and frequent heavy lifting. The delay in presentation is due to lack of awareness. It was also found in a study that feeling of embarrassment and social stigma could be the reason. (Abhyankar 2019) Pelvic Floor exercise and avoidance of heavy lifting may be beneficial at onset of symptom. For conclusion, POP awareness is crucial to empower women to prevent POP and seek treatment as soon as they are symptomatic.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S24

Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial

Pelvic reconstructive surgery may cause significant postoperative pain, especially with posterior colporrhaphy, contributing to a longer hospital stay and increased pain medication utilization. Regional blocks are being increasingly utilized in gynecologic surgery to improve postoperative pain and decrease opioid usage, yet preoperative pudendal blocks have not been used routinely during posterior colporrhaphy. This study aimed to compare the effect of preoperative regional pudendal nerve block using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and 3. We hypothesized that there would be a reduction in vaginal pain scores for the study group vs the control group over the first 72 hours. This was a double-blinded, randomized controlled trial that included patients undergoing a posterior colporrhaphy, either independently or in conjunction with other vaginal or abdominal reconstructive procedures. Patients were block randomized to receive 20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study) or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before the start of surgery. Double blinding was achieved by covering four 5-mL syringes containing the randomized local anesthetic. After induction of anesthesia, a pudendal nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary outcomes included total analgesic medication usage through postoperative day 3, postoperative voiding and defecatory dysfunction, and impact of vaginal pain on quality of life factors. A total of 120 patients were enrolled (60 in each group). There were no significant differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined liposomal and bupivacaine group at all time points vs the plain bupivacaine group. Median pain scores for the study and control groups, respectively, were 0 (0-2) and 2 (0-4) for postoperative day 1 (P=.03), 2 (1-4) and 3 (2-5) for postoperative day 2 (P=.05), and 2 (1-4) and 3 (2-5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days 2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%, P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity). Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine provided more effective vaginal pain control than plain bupivacaine alone for reconstructive surgery that included posterior colporrhaphy. Given the statistically significant decrease in vaginal pain in the study group, this block may be considered as a potential adjunct for multimodal pain reduction in this patient population.

Large Retroperitoneal Hematoma: A Rare Intraoperative Complication of Total Vaginal Hysterectomy

Retroperitoneal (RP) hematoma is a rare complication of total vaginal hysterectomy. A 45-year-old female G4P3013 with a history of abnormal uterine bleeding refractory to treatment by endometrial ablation and stress urinary incontinence underwent total vaginal hysterectomy, bilateral salpingectomy, bilateral uterosacral ligament suspension, anterior colporrhaphy, and cystoscopy. After the hysterectomy the left uterine artery pedicle was hemostatic; however, the patient became hemodynamically unstable and anemic. Laparoscopy revealed a stable zone III RP hematoma. Intraoperative observation revealed no further expansion of the hematoma. Left iliac angiography and aortography revealed there was no extravasation from the uterine arteries and gonadal vessels. Four days post-operative abdominal CT showed a stable hematoma. Hemodynamic instability resolved over the post-operative course. RP hematoma must be included in the differential for the evaluation of acute intraoperative hemodynamic instability with an unclear source.

Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation.

To correlate genital hiatus (GH) size with surgical failures in patients undergoing sacrospinous ligament fixation (SSLF) and compare anatomic outcomes after classification based on GH size. A retrospective review of 81 patients who underwent SSLF for apical prolapse from 2010 to 2016 at a teaching hospital. Anatomical outcome is reported using the Pelvic Organ Prolapse Quantifications System. A comparison of parametric continuous variables was performed using unpaired Student t test. Categorical variables were evaluated using Pearson's χ2 test and Fisher's exact test. A P value <0.05 was considered significant. Among the 81 patients, no difference in age, parity, body mass index, preoperative prolapse stage or follow-up time was noted between those whose surgery succeeded and those with failed surgery. Postoperatively, a widened GH was significantly associated with recurrent prolapse (P<0.001). When the preoperative size of the GH was dichotomized into widened (≥4cm) or normal (<4cm), there was a non-significant (P=0.444) trend of more failures in the widened GH group. A posterior colporrhaphy did not improve success. Both preoperative and postoperative widened GH correlated with having more surgical failures following SSLF. Importantly, postoperatively a normal size GH was significantly associated with more surgical success.