Evaluation and Resection of a Longitudinal Vaginal Septum in an Adult

OBJECTIVE

The objective of this video is to demonstrate the diagnosis, evaluation, and techniques for surgical management of a longitudinal vaginal septum, a rare müllerian anomaly.

DESIGN

This is a stepwise demonstration of evaluation and surgical techniques with video narration.

SETTING

The incidence of müllerian defects, which can include any anomaly in the fallopian tube, uterus, cervix, or vagina, has been estimated to be 2% to 4% [1]; 30% to 40% of patients with müllerian defects also have associated renal anomalies [1,2]. In normal development, the müllerian ducts fuse at 10 weeks' gestation and the septum between the 2 ducts is absorbed in a caudal to cephalad direction [3]. The exact incidence of complete longitudinal vaginal septa is unknown as they are very rare [4]. Longitudinal vaginal septa may cause dyspareunia, inability to have penetrative intercourse, labor dystocia, or hygiene issues and be very emotionally distressing for patients [5].

INTERVENTIONS

Preoperative evaluation of an adult with longitudinal vaginal septum that included a careful physical examination and abdominal and pelvic imaging. Intraoperative resection with key strategies: (1) placing a Foley catheter to help avoid urinary tract injuries and (2) intermittent rectal examinations to retract the rectum away from the plane of dissection.

CONCLUSION

Patients who present with longitudinal vaginal septa should undergo evaluation for uterine and renal anomalies. Here, we show that resection of longitudinal vaginal septa in adults is feasible and appropriate for patients who present with inability to have penetrative intercourse. Intraoperatively, care should be taken to avoid injuring the rectum or urinary tract.

Effect of Educational Video on Patient Adherence and Completeness of Voiding Diaries: A Randomized Trial

IMPORTANCE

Voiding diaries are clinically useful tools for elucidating the etiology of lower urinary tract symptoms. The utility of voiding diaries is challenged by low return rate and incomplete or inaccurate data entry.

OBJECTIVE

The objective was to determine the effect of the use of an educational video on patient adherence, completeness of intake and voiding diaries, and patient satisfaction.

STUDY DESIGN

In this trial, patients who were asked to complete an intake and voiding diary in a urogynecology clinic were randomized to receive standard education or enhanced education with an instructional video on how to complete the diary. Patients returned the diaries at their follow-up visits in the clinic. The primary outcome was the return rate of the diaries. Upon follow-up, patients filled out a survey reporting their satisfaction with instructions received. Diaries were graded by 3 blinded experts.

RESULTS

Eighty-five patients were enrolled, 42 in the standardized instructions arm and 43 in the video arm. A total of 26 patients (30.6%) filled out and returned an intake and voiding diary. Between groups, there was no difference in the rate of return of the diaries ( P = 0.59) or in completeness of the returned voiding diaries ( P = 0.60). The educational video did not change satisfaction between the groups; patients reported identical satisfaction between groups.

CONCLUSIONS

The addition of an instructional video on how to complete an intake and voiding diary did not increase patients' rate of return, completeness of diaries, or satisfaction with instructions provided to complete the diary.

Transvaginally Adjustable Apical Suspension and Compartment-Specific Tensioning in Vaginal Natural-Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Cadaveric and Live Patient Experience

Objective

This article provides a systematic approach to performing a vaginal natural-orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy (SCP) to create an anatomically aligned vaginal axis, an intraoperatively adjustable apical suspension, and variable compartment tensioning.

Methods

The technique presented for vNOTES SCP focuses on: (1) retroperitoneal tunneling; (2) direct sacrum access below the S-1 level, using uterosacral-ligament guidance; (3) transvaginal tensioning of the mesh to ensure both adequate vaginal length and cuff elevation using the DZOH apical-suspension technique; (4) circumvention of intrapelvic laparoscopic suturing; and (5) near-total peritoneal coverage of the mesh arms.

Results

This detailed description of a successful novel technique to perform vNOTES SCP was based on cadaveric experience as well as in live patients that is reproducible on living patients.

Conclusions

This apical suspension technique for vNOTES SCP may be a viable, reproducible, safe, and efficient transvaginal alternative to the commonly practiced minimally invasive approaches that involve abdominal-port placements. (J GYNECOL SURG 40:116).

Surgical Correction of Vaginal Agenesis via Modified Laparoscopic Vecchietti Procedure

OBJECTIVE

To describe surgical correction of vaginal agenesis via a modified laparoscopic Vecchietti procedure with the goal of disseminating knowledge and improving surgical technique CASE: An 18-year-old female presented with primary amenorrhea, age-appropriate secondary sex characteristics, a shallow vagina, and 46,XX karyotype. Imaging showed rudimentary uterine horns and normal ovaries, kidneys, and spine. Diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome type I was made. After an unsuccessful attempt at vaginal dilation and extensive counseling, the patient chose to have a laparoscopic Vecchietti procedure. Vecchietti vaginoplasty eliminates the need for grafts and creates a neovagina with accelerated vaginal dilation by stretching the introital mucosa with a spring mechanism.

RESULTS

A modified laparoscopic Vecchietti procedure was performed. Postoperatively, daily suture adjustments were made. When the device was removed after 7 days, the examination revealed a 9-cm vaginal canal, which was maintained with self-dilation.

Assessment of patient satisfaction with home vs office indwelling catheter removal placed for urinary retention after female pelvic floor surgery: a randomized controlled trial

BACKGROUND

Postoperative urinary retention is burdensome for patients. We seek to improve patient satisfaction with the voiding trial process.

OBJECTIVE

This study aimed to assess patient satisfaction with location of indwelling catheter removal placed for urinary retention after urogynecologic surgery.

STUDY DESIGN

All adult women who were diagnosed with urinary retention requiring postoperative indwelling catheter insertion after undergoing surgery for urinary incontinence and/or pelvic organ prolapse were eligible for this randomized controlled study. They were randomly assigned to catheter removal at home or in the office. Those who were randomized to home removal were taught how to remove the catheter before discharge, and were discharged home with written instructions, a voiding hat, and 10-mL syringe. All patients had their catheter removed 2 to 4 days after discharge. Those patients who were allocated to home removal were contacted in the afternoon by the office nurse. Subjects who graded their force of urine stream 5, on a scale of 0 to 10, were considered to have safely passed their voiding trial. For patients randomized to the office removal group, the voiding trial consisted of retrograde filling the bladder to maximum they could tolerate up to 300 mL. Urinating >50% of instilled volume was considered successful. Those who were unsuccessful in either group had catheter reinsertion or self-catheterization training in the office. The primary study outcome was patient satisfaction, measured based on patients' response to a question, "How satisfied were you with the overall removal process of the catheter?" A visual analogue scale was created to assess patient satisfaction and 4 secondary outcomes. A sample size of 40 participants per group were needed to detect a 10 mm difference in satisfaction between groups on the visual analogue scale. This calculation provided 80% power and an alpha of 0.05. The final number accounted for 10% loss to follow up. We compared the baseline characteristics, including urodynamic parameters, relevant perioperative indices, and patient satisfaction between the groups.

RESULTS

Of the 78 women enrolled in the study, 38 (48.7%) removed their catheter at home and 40 (51.3%) had an office visit for catheter removal. Median and interquartile range for age, vaginal parity, and body mass index were 60 (49-72) years, 2 (2-3), and 28 (24-32) kg/m2, respectively, in the overall sample. Groups did not differ significantly in age, vaginal parity, body mass index, previous surgical history, or type of concomitant procedures. Patient satisfaction was comparable between the groups, with a median score (interquartile range) of 95 (87-100) in the home catheter removal group and 95 (80-98) in the office catheter removal group (P=.52). Voiding trial pass rate was similar between women who underwent home (83.8%) vs office (72.5%) catheter removal (P=.23). No participants in either group had to emergently come into the office or hospital due to inadequate voiding afterwards. Within 30 days post operatively, a lower proportion of women in the home catheter removal group (8.3%) had urinary tract infection, compared to patients in the office catheter removal group (26.3%) (P=.04).

CONCLUSION

In women with urinary retention after urogynecologic surgery, there is no difference in satisfaction concerning the location of indwelling catheter removal when comparing home and office.

Sling plication for persistent stress urinary incontinence after midurethral sling

INTRODUCTION AND HYPOTHESIS

Persistent or recurrent stress urinary incontinence after midurethral sling placement is not uncommon. Treatment options include placement of a second midurethral sling, autologous fascial sling, retropubic urethropexy, or urethral bulking. Shortening of the sling by plication has also been suggested as an alternative option which may reduce operative time, cost, risk of trocar injury, and mesh burden. In this video, we aimed to demonstrate our technique and experience on sling plication.

METHODS

The key steps of the procedure are as follows: (1) suburethral incision and sharp dissection to identify the sling; (2) mobilization of the suburethral portion of the sling; (3) plication with two interrupted, horizontal sutures placed 1 cm laterally on each side; (4) application of upward pressure while tying the sutures and tensioning the sling. In our experience, we have found this technique to be most successful for retropubic slings, especially when performed within 2-12 weeks of the initial surgery.

CONCLUSIONS

Sling plication is an effective and minimally invasive option to treat persistent stress urinary incontinence after failed midurethral sling procedures. It avoids additional mesh burden or more invasive retropubic surgery and should be offered as a treatment option for appropriately counseled patients.

Current state of bladder diary: a survey and review of the literature

INTRODUCTION AND HYPOTHESIS

The objectives of this study are (1) to assess practice patterns among urogynecology/female pelvic medicine and reconstructive surgery (FPMRS) providers regarding the use of bladder diaries (BD) and (2) to review the literature regarding BD.

METHODS

For the first objective, a survey was emailed to United States-based urogynecology providers in 2019 querying frequency of use of bladder diaries (F_BD), indications, problems, patient education methods, and perception of utility. Chi-square tests and multiple logistic regression were performed. For the second objective, we reviewed literature published in English by searching the terms "voiding," "bladder," or "incontinence," in combination with "diary," "log," or "questionnaire."

RESULTS

A total of 371 of 851 (43.5%) contacted providers responded. Nearly 80% were attending physicians, 75.5% of whom completed the FPMRS fellowship; 20.8% of all respondents and nearly 25% of fellowship-trained attendings reported F_BD <20% in the last year. FPMRS providers were more likely to report F_BD >80%. A total of 97.5% of respondents cited difficulty in using BD. Most (71.6%) taught patients to use BD themselves or shared responsibility with a nonphysician staff member (53.4%). BD is a validated and valuable instrument; however, there are obstacles to its use. Despite recent innovations including electronic and automated BD, there is a paucity of data regarding the provider-viewed challenges in implementing BD.

CONCLUSIONS

The literature supports the use of BD; however, many survey respondents, including fellowship-trained attendings, never or rarely use BD. Most respondents reported difficulty in using BD. More research is needed to improve the ease, accuracy, and widespread adaptation of BD use in clinical practice.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis

IMPORTANCE

Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial.

OBJECTIVE

We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective.

STUDY DESIGN

We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios).

RESULTS

Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications.

CONCLUSIONS

Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Laparoscopic Colpo-Pneumo Occluder as a Vaginal Mold for Vaginal Reconstruction

BACKGROUND

Currently, there is no commercially available soft vaginal mold designed for reconstructive surgeries for congenital vaginal anomalies. Stricter operating room regulations discourage the use of makeshift molds from foams and gloves. A colpo-pneumo-occluder balloon is designed to maintain pneumoperitoneum after colpotomy in laparoscopic hysterectomies and is approved for use in vaginal surgeries.

CASE

A 17-year-old girl with a congenital transverse vaginal septum experienced recurrent obstruction and hematocolpos. We successfully used a colpo-pneumo-occluder balloon as a vaginal mold during postoperative care. Its size and design make this device ideal for use in vaginal reconstructive surgeries in adolescents.

SUMMARY AND CONCLUSION

The laparoscopic colpo-pneumo-occluder, a sterile vaginal device, is appropriate to use as an adjustable, soft vaginal mold for correction of congenital and acquired vaginal anomalies.

Optimizing the robotic surgery team: an operations management perspective

INTRODUCTION AND HYPOTHESIS

To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions.

METHODS

All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify 'optimal' surgical team configuration.

RESULTS

The database included 359 consecutive RASCPs, all performed for stage III-IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3 years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7 kg/m². A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively.

CONCLUSION

Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.

Effect of obesity on perioperative outcomes of laparoscopic hysterectomy

OBJECTIVE

To compare the effect of obesity on perioperative outcomes in women undergoing laparoscopic hysterectomy.

STUDY DESIGN

In this retrospective cohort study, perioperative outcomes of all women who underwent laparoscopic supracervical hysterectomy (LSH) or total laparoscopic hysterectomy (TLH) for benign conditions were compared between obese (body mass index > or = 30 kg/m2) and nonobese women.

RESULTS

Baseline characteristics were similar between 320 (33.0%) obese and 550 (67%) nonobese women except for race and the rates of hypertension and diabetes. The adjusted rates of urinary tract injury, vaginal cuff dehiscence, postoperative fever, and ileus were similar between the groups. For obese women, however, bleeding requiring transfusion was almost 3-fold (3.1 vs. 1.1%, adjusted odds ratio [AOR] 2.93, 95% confidence interval [CI] 1.10-7.80) and laparotomy risk was approximately 2-fold (7.5 vs. 3.5%, AOR 2.35, 95% CI 1.30-4.24) increased. The rate of urinary tract injury was 3.2% when obese women had TLH, but it was 0.3% for LSH performed on nonobese women. Of all 7 cuff dehiscences, 5 (71%) occurred in nonobese women undergoing TLH.

CONCLUSION

Obesity increased the risk of bleeding requiring transfusion and conversion to laparotomy but did not influence the other perioperative complications. On subgroup analysis, LSH in nonobese women seems to result in best outcomes.

Massive subcutaneous emphysema in robotic sacrocolpopexy

Robotic sacrocolpopexy may increase insufflation complications including massive subcutaneous emphysema.

The advent of robotic surgery has increased the popularity of laparoscopic sacrocolpopexy. Carbon dioxide insufflation, an essential component of laparoscopy, may rarely cause massive subcutaneous emphysema, which may be coincident with life-threatening situations such as hypercarbia, pneumothorax, and pneumomediastinum. Although the literature contains several reports of massive subcutaneous emphysema after a variety of laparoscopic procedures, we were not able to identify any report of this complication associated with laparoscopic or robotic sacrocolpopexy. Massive subcutaneous emphysema occurred in 3 women after robotic sacrocolpopexy in our practice. The patients had remarkable but reversible physical deformities lasting up to 1 week. A valveless endoscopic dynamic pressure system was used in all 3 of our cases. Our objective is to define the risk of massive subcutaneous emphysema during robotic sacrocolpopexy in light of these cases and discuss probable predisposing factors including the use of valveless endoscopic dynamic pressure trocars.

Vaginal myofibroblastoma with prostatic glands: is there an association with tamoxifen use? A case report

BACKGROUND

Both ectopic prostate tissue in the female genital tract and vaginal myofibroblastoma have rarely been reported in the literature. Tamoxifen use has been associated with the development of vaginal myofibroblastoma.

CASE

A 76-year-old, multiparous woman who had taken tamoxifen for breast cancer presented with postmenopausal bleeding and a vaginal mass. Endometrial work-up revealed a benign polyp, and the polypoid tumor in the vagina was found to be a myofibroblastoma harboring ectopic prostatic glands.

CONCLUSION

To our knowledge this is the first case of these two rare pathologic entities occurring together. Of note, this patient also had a history of tamoxifen therapy, like some of the previous patients with vaginal myofibroblastoma.

Does surgical volume influence short-term outcomes of laparoscopic hysterectomy?

OBJECTIVE

To evaluate whether surgical volume has an impact on short-term outcomes of laparoscopic hysterectomy.

STUDY DESIGN

This is a retrospective analysis of 1016 laparoscopic hysterectomies.

RESULTS

The surgeons were divided into 2 groups based on a cutoff of 30 cases. Patient characteristics, the rates of laparotomy (4.5% vs 6.7%), and serious complications (3.6% vs 5.5%) were similar between 9 "high" and the remaining 39 "low volume" gynecologists, respectively (P < .05). Mean operating time was longer in the "low volume" group. Compared with their first 29 hysterectomies, the "high volume" surgeons decreased their operating time significantly in their subsequent cases. The "high volume" surgeons improved their conversion rate (9.2% vs 2.4%; P < .0001) over time but not their serious complications.

CONCLUSION

In laparoscopic hysterectomy, increasing the surgical volume can reduce the operating time and the risk for conversion to laparotomy but not the rate of serious complications.

Pessary use in pelvic organ prolapse and urinary incontinence

With the aging population in the United States, there has been a renewed interest in pessaries as a conservative alternative to surgical repair for pelvic organ prolapse (POP). They present a good option for patients who have not completed childbearing, do not desire surgery, or are poor surgical candidates. Long-term pessary use is a safe and effective option for patients with POP and stress urinary incontinence. Although serious side effects are infrequent, insertion and removal of most pessary types still pose a challenge for many patients. Pessary design should continue to improve, making its use a more attractive option.

Large vesicovaginal fistula in women with pelvic organ prolapse: the role of colpocleisis revisited

Successful repair of large vesicovaginal fistulas poses a significant challenge in surgically unfit older women with pelvic organ prolapse. Two women, at ages of 85 and 93, referred for involuntary urine loss were found to have neglected pessaries resulting in large vesicovaginal fistulas. After the removal of the pessary, fistula repair and LeFort colpocleisis were done with success. At 12 months postoperatively, the patients were free of leakage and prolapse. For frail, elderly women with large vesicovaginal fistula and pelvic organ prolapse, addition of LeFort colpocleisis to the repair provides an effective treatment for both.

Traumatic atlanto-occipital dislocation with survival: a case report and review of the literature

The number of patients who have survived traumatic atlanto-occipital dislocation, the usual outcome of which is death from brain stem transection, has increased in the past two decades due to improvements in on-scene resuscitation and transportation. This case of survival after traumatic atlanto-occipital dislocation is of interest because the patient had a complete neurologic recovery and a magnetic resonance imaging (MRI) study was obtained to confirm the diagnosis and rule out associated injuries.