More With Less: Single-Incision Sling Insertion Techniques

STUDY OBJECTIVE

To demonstrate reproducible procedures for efficient single-incision sling insertion and troubleshooting.

DESIGN

Narrated video footage with stepwise demonstration of single-incision sling insertion technique with anchor system.

SETTING

The mesh midurethral sling is a highly effective and safe procedure that is considered the gold standard for surgical treatment of stress urinary incontinence. Retropubic and transobturator approaches for midurethral slings have similar subjective cure rates with differing surgical risk profiles [1,2]. The retropubic route has a higher risk of injury to the bladder, nerves, and vascular structures, whereas the obturator approach carries a risk of groin or thigh pain [3-5]. Use of a single-incision sling decreases these risks and allows flexibility to perform the procedure without sedation or general anesthesia. Recent literature demonstrates similar subjective and objective success and safety of single-incision slings compared with both retropubic and transobturator approaches, although long-term data are forthcoming [5].

INTERVENTIONS

We demonstrate a stepwise approach for the insertion of a single-incision sling using a helical trocar. Easily reproducible procedures for setup and sling anchor management allow for efficient placement without assistance. In addition, we outline hand positioning, trocar management, and anchor deployment with troubleshooting techniques for potential placement difficulties. Finally, we review methods for sling tensioning to prevent complications such as voiding dysfunction and mesh or suture exposures.

CONCLUSION

Given that single-incision slings are more likely to be performed under local anesthesia and are less invasive with decreased recovery time, it has the potential to become the preferred approach in the future. This video demonstrates clear and detailed steps to facilitate successful placement of the single-incision mesh midurethral sling.

Urethral Diverticulum Marsupialization With Modified Spence-Duckett Procedure

OBJECTIVE

To demonstrate a modified approach to the Spence-Duckett procedure for treatment of a distal urethral diverticulum. A urethral diverticulum is an outpouching of urethral mucosa occurring in 2-5% of the population.1 They are thought to commonly arise due to chronic inflammation or infection of the peri-urethral glands.2,3 MATERIALS AND METHODS: We present a 37-year-old female with vaginal bulge, dyspareunia, and dysuria. On examination, she had a 2-centimeter tender mass abutting the distal urethra. Imaging such as ultrasound or magnetic resonance imaging is critical to map the location of the diverticula along the urethra and extent of urethral involvement as it can inform surgical technique. Diverticula are typically located postero-laterally at the mid- or distal urethra; however, they can be found at any location along the urethra.2,3 Care must be taken to avoid disruption of the continence mechanism at the mid-urethra to prevent incontinence after surgery. Magnetic resonance imaging revealed a 1.7 × 1.7 × 1.8 centimeter unilocular cystic structure at the left posteromedial distal urethra consistent with a urethral diverticulum. The patient desired surgical management.

RESULTS

Spence and Duckett traditionally described insertion of one blade of the Metzenbaum scissors in the urethra with incision into the diverticulum and anterior vaginal wall followed by marsupialization.4 Given the small size of the diverticular ostium identified, we opted to make an incision using a scalpel from the ostium down the posterior aspect of the urethra and proximally to the anterior vaginal wall. We then excised the diverticular sac prior to marsupialization. At 6 weeks after surgery, she had full resolution of her symptoms without development of urinary incontinence. Pathologic examination is important because while rare, cancers can originate from urethral diverticula, with a prevalence of 6-9%.5 Pathology was consistent with urethral diverticulum and negative for dysplasia.

CONCLUSION

While effective, the Spence-Duckett technique is described as a "generous meatotomy" with risks of urethral shortening. Our modified approach reduces these risks, resolves bothersome symptomatology, improves cosmesis, and minimizes risk of anatomic or functional urethral compromise.

Colpocleisis Techniques: An Open-and-shut Case for Advanced Pelvic Organ Prolapse

OBJECTIVE

To highlight several advanced surgical techniques for all types of colpocleisis. Pelvic organ prolapse is a common condition that affects up to 40% of the postmenopausal female population.1,2 Particularly for women with advanced pelvic organ prolapse who no longer desire penetrative vaginal intercourse and with multiple medical comorbidities, the obliterative approach is preferred due to decreased anesthetic needs, operative time, and perioperative morbidity.3 Additionally, colpocleisis is associated with a greater than 95% long-term efficacy with low patient regret, high satisfaction, and improved body image.4,5 MATERIALS AND METHODS: The umbrella term of "colpocleisis" encompasses a uterine-sparing procedure, the LeFort colpocleisis, colpocleisis with hysterectomy, and posthysterectomy vaginal vault colpocleisis. We demonstrate the surgical steps of performing each type of colpocleisis as well as levator myorrhaphy and perineorrhaphy, which are typically included to reinforce the repair.

RESULTS

To streamline the LeFort colpocleisis procedure, we demonstrate use of electrosurgery to mark out the epithelium and methods to create the lateral tunnels with LeFort colpocleisis with and without the use of a urinary catheter. We also present techniques that can be utilized across all types of colpocleisis including the push-spread technique for dissection, tissue retraction with Allis clamps and rubber bands on hemostat clamps to improve visualization, and approximation of the anterior and posterior vaginal muscularis to close existing space. Attention must be paid not to proceed past the level of the urethrovesical junction to avoid angulation of the urethra. We use an anatomic model to demonstrate appropriate suture placement during levator myorrhaphy to facilitate an adequate purchase of the levator ani muscles in order to adequately narrow the vaginal opening. Ultimately the goal of the colpocleisis procedure is a well-approximated, obliterated vagina, approximately 3 cm in depth and 1 cm in width.

CONCLUSION

The skills demonstrated enable the surgeon to maximize efficiency and surgical outcomes for an effective obliterative procedure for advanced stage pelvic organ prolapse.

Reduced versus standard intradetrusor OnabotulinumtoxinA injections for treatment of overactive bladder

BACKGROUND

Intradetrusor onabotulinumtoxinA injection is an effective advanced treatment for overactive bladder. While the effective dosages have been well studied, very little data exist on treatment efficacy using differing injection techniques. The objective of this study was to determine whether the efficacy of a reduced injection technique of 5 injection sites was noninferior to the standard technique of 20 injection sites of intradetrusor onabotulinumtoxinA for treatment of overactive bladder.

METHODS

In this randomized noninferiority trial, men and women seeking treatment of overactive bladder with intradetrusor onabotulinumtoxinA injections were randomized to receive 100 units administered via either a reduced injection technique of 5 injection sites or a standard injection technique of 20 injection sites. Subjects completed a series of standardized questionnaires at baseline and at 4-12 weeks postprocedure to determine symptom severity and treatment efficacy. The primary outcome was treatment efficacy as determined by Overactive Bladder Questionnaire-Short Form with a noninferiority margin of 15 points. Secondary outcomes were incidence of urinary tract infection and urinary retention requiring catheterization.

RESULTS

Data from 77 subjects were available for analysis with 39 in the control arm (20 injections) and 38 in the study arm (5 injections). There was a significant improvement in both arms from baseline to follow-up in Overactive Bladder Questionnaire-Short Form and International Consultation on Incontinence Questionnaire scores (p < 0.001). Overall treatment success was 68% with no statistically significant difference between arms. A significant difference between arms was found on the Overactive Bladder Questionnaire-Short Form quality of life survey favoring the control arm (confidence interval [CI]: 0.36-20.5, p = 0.04). However, there were no significant differences between arms in the remaining validated questionnaires. The study arm did not demonstrate noninferiority to the control arm. Subjects in the study arm were significantly more likely to express a willingness to undergo the procedure again (odds ratio = 3.8, 95% CI: 1.42-10.67, p = 0.004). Adverse events did not differ between arms.

CONCLUSIONS

A reduced injection technique for administration of intradetrusor onabotulinumtoxinA demonstrates similar efficacy to the standard injection technique but did not demonstrate noninferiority. Subjects preferred the reduced injection technique over the standard technique. A reduced injection technique is a safe and effective alternative to the standard technique.

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

BACKGROUND

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.

OBJECTIVE

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.

STUDY DESIGN

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.

RESULTS

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).

CONCLUSION

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.

Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population

We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.