Pessaries and rectovaginal fistulae: consequences of delayed clinical follow-up in the Covid-19 pandemic
INTRODUCTION AND HYPOTHESIS:While 2017 guidelines from The American College of Obstetricians & Gynecologists called for pessary replacement every 3 to 4 months, a recent study in Obstetrics and Gynecology suggested that uninterrupted pessary use up to 6 months is not an independent risk factor for development of pessary-related complications. METHODS:Our recent experience throughout the Covid-19 pandemic highlights the potential ramifications of delayed clinical follow-up. RESULTS:During the Covid-19 pandemic, 3 of our patients developed rectovaginal fistulae secondary to Gellhorn pessary erosion in the context of delayed clinical follow-up. Our patients had previously attended routine appointments every 3 months without complications until missed appointments secondary to the pandemic led to fistulae formation. CONCLUSION:We believe that delayed clinical follow-up of pessary management beyond 3 months due to the Covid-19 pandemic may lead to fistula complications in elderly women with Gellhorn pessaries.
Robotic Repair of Complicated Vesico-[utero]/Cervicovaginal Fistula after Cesarean Section
STUDY OBJECTIVE/OBJECTIVE:To demonstrate intra- and postoperative steps in a successful management of a complicated vesico-[utero]/cervicovaginal fistula. DESIGN/METHODS:Stepwise demonstration of the technique with narrated video footage. SETTING/METHODS:A urogenital fistula in developed countries mostly occurs after gynecologic surgeries but rarely from obstetric complications. The main treatment of a urogenital fistula is either transvaginal or transabdominal surgical repair. We present a case of a 36-year-old woman, gravida 3 para 3-0-0-3, who developed a complicated large vesico-[utero]/cervicovaginal fistula after an emergent repeat cesarean section. Robotic repair was performed 2 months after the injury using the modified O'Connor method. Blood loss was minimal, and the patient was discharged from the hospital 1 day postoperatively. Follow-up showed complete healing of the fistula with no urine leakage, frequency of urination, or dyspareunia. The patient resumed normal bladder function and menstrual period up to 4 months after the repair procedure. INTERVENTIONS/METHODS:The basic surgical principle of urogenital fistula repair is demonstrated: (1) development of vesicovaginal spaces by dissection of the bladder from the uterus and the vagina, (2) meticulous hemostasis, (3) adequate freshened of the fistula edges, (4) tension-free and watertight closure of the bladder. We also demonstrate some other techniques that have developed though our own practice: (1) facilitating bladder distention by temporarily blocking the fistula, (2) placement of a ureteral catheter to protect the ureters, (3) interposition with omental flap, (4) single layer through and through closure of a cystotomy with 2-0 V-Loc suture (Covidien, Irvington, NJ). CONCLUSION/CONCLUSIONS:Complicated urogenital fistulas may be repaired successfully using minimally invasive surgery using robotic assistance, enabling less blood loss, faster recovery, shorter hospital stay, and fewer complications, etc.
Improved Understanding of Female Pelvic Medicine and Reconstructive Surgery Concepts Through Targeted Case-Based Educational Intervention: A Pilot Study
OBJECTIVES/OBJECTIVE:Given the complex anatomy and pathophysiology of urogynecologic disorders, obstetrics and gynecology residents can have difficulty learning the subject's principles. There are no standardized resources for educators in this subspecialty. We hypothesized that our case-based educational intervention was associated with enhanced knowledge and greater resident satisfaction versus traditional urogynecology lectures. METHODS:This is a prospective study involving 19 obstetrics and gynecology residents at a single institution. Residents participated in three 1-hour case-based lectures, which included prelecture and postlecture topic knowledge assessments. Nonparametric Wilcoxon signed-rank tests were used to compare the before and after responses. Resident satisfaction was assessed using a 5-point Likert scale questionnaire. RESULTS:The median scores for the pretraining and posttraining assessments of resident urogynecology subject knowledge were 8 (5-10) and 10 (8-10), respectively. A stratified analysis was performed based on postgraduate year (PGY) and median prelectures and postlectures scores showed statistically significance (P < 0.001). Analysis of the PGY subgroups demonstrated statistical significance in PGY1 (P = 0.004), PGY2 (P = 0.008), and PGY3 (P = 0.03). However, the PGY4 subgroup (P = 0.06) did not reach statistical significance.All residents regardless of PGY level either agreed or strongly agreed that the case-based educational intervention enhanced resident knowledge, engagement, and clarity of the relevant teaching points and decreased resident stress about urogynecology topics. CONCLUSIONS:The case-based educational intervention significantly improved resident knowledge in urogynecology and enhanced resident satisfaction with this teaching method versus traditional lectures.
51: Robot assisted repair of vesico-utero/cervico-vaginal fistula
Outcomes of stress urinary incontinence in women undergoing TOT versus Burch colposuspension with abdominal sacrocolpopexy
INTRODUCTION AND HYPOTHESIS/OBJECTIVE:To compare postoperative rates of stress urinary incontinence (SUI) in patients with pelvic organ prolapse and SUI undergoing abdominal sacrocolpopexy (ASC) with Burch colposuspension or a transobturator tape (TOT) sling. METHODS:In this retrospective cohort study, medical records of 117 patients who underwent ASC with Burch (nâ€‰=â€‰60) or TOT (nâ€‰=â€‰57) between 2008 and 2010 at NYU Winthrop Hospital were assessed. Preoperative evaluation included history, physical examination, cough stress test (CST), and multichannel urodynamic studies (MUDS). Primary outcomes were postoperative continence at follow-up up to 12Â weeks. Patients considered incontinent reported symptoms of SUI and had a positive CST or MUDS. Secondary outcomes included intra- and postoperative complications. Associations were analyzed by Fisher's exact, McNemar's and Wilcoxon-Mann-Whitney tests. RESULTS:The groups were similar regarding age, BMI, parity, Valsalva leak point pressure (VLPP), and prior abdominal surgery (pâ€‰=â€‰0.07-0.76). They differed regarding preoperative SUI diagnosed by self-reported symptoms, CST, or MUDS (TOT 89.5-94.7%, Burch 60.7-76.3%, pâ€‰<â€‰0.0001-0.007). The TOT group had lower rates of postoperative SUI (TOT 12.5%, Burch 30%, ORâ€‰=â€‰0.15, 95% CI 0.04, 0.62). Relative risk reduction (RRR) in postoperative SUI for the TOT group compared with the Burch group was 79%-86%. There were no differences concerning intra- and postoperative complications. The Burch group had a higher rate of reoperation for persistent/recurrent SUI (Burch 25%, TOT 12% pâ€‰=â€‰0.078). CONCLUSIONS:The TOT group experienced a greater reduction in postoperative incontinence, and the Burch group underwent more repeat surgeries. The TOT sling may be superior in patients undergoing concomitant ASC.
Update on Urinary Tract Markers in Interstitial Cystitis/Bladder Pain Syndrome
Interstitial cystitis (IC)/painful bladder syndrome/bladder pain syndrome (BPS) is a chronic hypersensory condition of unknown etiology. Moreover, the optimal modality for diagnosing IC remains disputed. Several urinary markers have been investigated that may have potential utility in the diagnosis or confirmation of IC/BPS. Thus, inflammatory mediators, proteoglycans, urinary hexosamines, proliferative factors, nitric oxide (NO), BK polyomavirus family, and urothelial proinflammatory gene analysis have been found to correlate with varying degrees with the clinical diagnosis or cystoscopic findings in patients with IC/BPS. The most promising urinary biomarker for IC/BPS is antiproliferative factor, a sialoglycopeptide that has demonstrated inhibitory effects on urothelial cell proliferation and a high sensitivity and specificity for IC/BPS symptoms and clinical findings. In this article, we review the urinary markers, possible future therapies for IC/BPS, and the clinical relevance and controversies regarding the diagnosis of IC/BPS.
Postoperative adhesion formation in a rabbit model: monopolar electrosurgery versus ultrasonic scalpel
BACKGROUND AND OBJECTIVES/OBJECTIVE:To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period. METHODS:Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS:There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30). CONCLUSION/CONCLUSIONS:Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.
Management of infected urethral diverticulum with urethral dilation [Case Report]
BACKGROUND:Urethral diverticula are rare but underdiagnosed entities that may cause a variety of urinary and pelvic symptoms in women. Management can be very challenging, especially in cases of chronic infection. CASE/METHODS:A 69-year-old gravida 4, para 2 woman with a history of type 2 diabetes and hypothyroidism presented with long history of a painful midline 3-cm suburethral cystic mass, recurrent urinary tract infections, dysuria, dyspareunia, and incomplete voiding. The diagnosis was consistent with an infected urethral diverticulum unresponsive to multiple courses of oral antibiotics. Given the patient's comorbidities and the persistence of infection of the diverticulum, conservative treatment with urethral dilation was performed before surgical treatment. Urethral dilation successfully alleviated the patient's symptoms; the surgical treatment was not ultimately required, and the patient continues to be completely asymptomatic well over 17 months later. CONCLUSIONS:We present a unique case of infected urethral diverticulum, which was conservatively treated with dilatation and resulted in resolution of all symptoms, and there is no need for further surgical management.
Rare case of neglected pessary presenting with concealed vaginal hemorrhage [Case Report]
BACKGROUND:Vaginal pessaries are commonly used for management of pelvic organ prolapse. Severe complications can occur in neglected cases. CASE/METHODS:A 91-year old woman with significant comorbidities presented with large concealed vaginal bleeding and history of vaginal pessary placement 14 years before. On examination, an impacted Gellhorn pessary in the vagina was noted with some spotting. Serum blood tests revealed severe anemia and renal insufficiency. An abdominal and pelvic computed tomographic scan confirmed a Gellhorn pessary and a large vaginal accumulation of blood superior to impaction. The pessary was surgically removed vaginally under anesthesia. Recovery was uneventful, and the patient was discharged 1 week later. CONCLUSION/CONCLUSIONS:Our case underlines the need of follow-up and compliance after pessary placement for early detection of complications.
Delayed small bowel obstruction after robotic-assisted sacrocolpopexy [Case Report]
We report 2 unusual cases of partial bowel obstruction resulting from adherence to a barbed suture presenting 3 to 4 weeks after robotic-assisted sacrocolpopexy for uterovaginal prolapse. Both patients underwent an uncomplicated robotic-assisted supracervical hysterectomy and sacrocolpopexy. Immediate postoperative recovery was uncomplicated. Three to four weeks after surgery, both patients presented with symptoms of nausea, vomiting, and abdominal pain and were found to have small bowel obstructions requiring a return to the operating room. Upon surgical exploration, a loop of small bowel was found to be adhered to a segment of the barbed suture at the sacral promontory, which had been used to close the peritoneum over the mesh. Subsequent to release, both patients had an uneventful recovery.