Aimee L. Smith

Obliterative LeFort colpocleisis in a large group of elderly women.

OBJECTIVE: To report on anatomical and functional outcomes, patient satisfaction, and associated morbidity and mortality in patients undergoing LeFort colpocleisis. METHODS: This was a retrospective case series of LeFort colpocleisis performed from January 2000 to October 2011. Data obtained from a urogynecologic database included demographics, comorbidities, medications, and urinary and bowel symptoms. Prolapse was quantified using the pelvic organ prolapse quantification (POP-Q) examination. Operative characteristics were recorded. All patients underwent pelvic examination and POP-Q assessment at follow-up visits. Patients also were asked about urinary and bowel symptoms as well as overall satisfaction. All intraoperative and postoperative surgical complications were recorded. RESULTS: Three hundred twenty-five patients underwent LeFort colpocleisis. Fifteen patients were excluded from the analysis because of incomplete data. The mean age was 81.3±5.3 years. Comorbidities were common, with 74.1% of the patients having at least one concomitant medical condition. The procedure was performed under spinal anesthesia in 67%. Additional procedures at the time of colpocleisis included incontinence procedures (79%) and dilation and curettage (46%). Mean follow-up was 45 (range 2–392) weeks. Anatomical success rate was 98.1% and patients were highly satisfied, with 92.9% reported being “cured” or “greatly improved.” Complication and mortality rates were 15.2% and 1.3%, respectively. CONCLUSION: Colpocleisis is an effective and low-risk procedure with high anatomical success rates and patient satisfaction. Associated morbidity and mortality related to the procedure are low. Colpocleisis remains an excellent surgical option for the elderly patient with advanced pelvic organ prolapse. LEVEL OF EVIDENCE: III

Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: Outcomes based on location and periurethral distribution of the bulking agent

Introduction and hypothesisOur aim was to use three-dimensional enodovaginal ultrasound (3D EVUS) to identify sonographic parameters that are associated with successful outcomes following injection of Macroplastique.MethodsThree hundred and sixty degree 3D EVUS was performed in 100 treatment-naïve patients following Macroplastique injection. The location, volumes, periurethral distribution, and distance of the hyperechoic densities from the urethrovesical junction were assessed. The patients were divided into two groups: group A (n = 72): patients who had good clinical outcome and group B (n = 28): patients who were not improved or worsened. The two groups were compared with respect to the ultrasound parameters measured.ResultsGroup A had a greater proportion of women with Macroplastique located in the proximal urethra, while midurethral location was found to be significantly more frequent in group B (p = 0.036). The odds of a circumferential periurethral distribution in group A were 13.62 times the odds in group B (95% CI: 5.12–56.95). When the location of the injection and the type of periurethral distribution were considered together, it was found that when the site of injection was proximal, the odds of circumferential distribution in group A was significantly greater than those in group B (odds ratio [95% CI]: 22 [3.05–203.49]; p < 0.001).ConclusionProximally located Macroplastique and circumferential periurethral distribution of Macroplastique are individually associated with successful outcomes following the injection. The combination of circumferentially distributed and proximally located Macroplastique is associated with the best short-term clinical outcomes.

Predictors of successful salpingo-oophorectomy at the time of vaginal hysterectomy.

STUDY OBJECTIVE To determine prognostic factors related to successful salpingo-oophorectomy in menopausal women at the time of vaginal hysterectomy. DESIGN Retrospective cohort study (Canadian Task Force Classification II-2). SETTING Tertiary care center. PATIENTS A total of 309 postmenopausal ≥60 years old with pelvic floor disorders. INTERVENTIONS Vaginal hysterectomy with attempted prophylactic salpingo-oophorectomy. MEASUREMENTS Factors associated with ability to achieve vaginal salpingo-oophorectomy. MAIN RESULTS 203 (65.7%) achieved successful removal of 1 or both ovaries, and 106 (34.3%) were not amenable to removal. Younger age and shorter cervical length were predictors of salpingo-oophorectomy. Cervical elongation of ≥7 cm, exteriorized cervical/uterine prolapse, and anterior vaginal wall prolapse beyond the hymen were associated with lower likelihood of achieving salpingo-oophorectomy. CONCLUSIONS Patient age and cervical length are independent factors that influence the success of accomplishing salpingo-oophorectomy at the time of vaginal hysterectomy.

A case–control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery

To identify risk factors leading to the development of postoperative ileus and small‐bowel obstruction (SBO) after benign gynecologic surgery.

Management of ileus and small-bowel obstruction following benign gynecologic surgery.

To describe practice preferences for the diagnosis and management of ileus and small‐bowel obstruction (SBO) following benign gynecologic surgery.

Biologic grafted repair of urethrovaginal fistula and concomitant synthetic sling

The utilization of a biologic graft interposition allows for a successful fistula repair and concomitant synthetic sling without an increase in complications.

An Inexpensive Polypropylene Patch Sling for Treatment of Intrinsic Sphincteric Deficiency

STUDY OBJECTIVE To evaluate an inexpensive polypropylene sling in patients with intrinsic sphincteric deficiency (ISD). DESIGN Case series (Canadian Task Force classification II-2). SETTING Cleveland Clinic Florida teaching hospital. PATIENTS Analysis of 161 patients with ISD who underwent a surgeon-assembled polypropylene (Prolene) patch sling procedure. INTERVENTION Polypropylene patch sling surgery was performed in all study patients with urinary stress incontinence due to ISD. MEASUREMENTS AND MAIN RESULTS All patients underwent urogynecologic evaluation including multichannel urodynamics. Outcome measures included a standardized stress test, patient-reported cure rate, surgical complications, and postoperative voiding dysfunction. Medical records for the 161 patients who underwent the procedure were available for review. Mean patient age was 62.4 years. Twenty-five patients (16%) had concomitant detrusor overactivity. Mean follow-up was 3.6 years. The stress test yielded negative findings in 93.4% of patients. Complete continence was reported by 80.3% of patients, and marked improvement by 7%. The estimated cost of the sling was

Urogynecology digest: Presented by Aimee L. Smith

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Body image, regret, and satisfaction following colpocleisis

272, depending on the materials used. Two patients experienced urinary retention requiring urethrolysis. Three required sling revision because of healing problems. CONCLUSION Use of a polypropylene patch sling is an effective treatment for ISD and is less expensive than currently available sling kits.

Repeat versus primary slings in patients with intrinsic sphincter deficiency

This large cohort study evaluates the long-term effect of the mode of delivery on the prevalence of urinary incontinence in a homogeneous population of primiparae. The authors extracted data from the national Swedish Medical Birth Register, which includes >98 % of all births in Sweden. Inclusion criteria were singleton primiparae who delivered between 1985 and 1988. Three modes of delivery were evaluated, “vaginal delivery,” “acute cesarean section” (after the onset of labor), and “elective cesarean section” (before the onset of labor). A 31-item questionnaire was sent to 9,423 patients, 6,148 (65.2 %) responded and 5,236 were included in the analysis. The question, “Do you have involuntary loss of urine?” was used to identify urinary incontinence (UI). At a follow-up time of 21 years, the prevalence of UI was 67% higher (OR 1.67; 95 % CI 1.45–1.92) following vaginal delivery (40.3 %) compared with cesarean section (28.8 %). Additionally, the prevalence of UI persisting for >10 years after vaginal delivery was 10.1 % compared with 3.9 % (OR 2.75; 95 % CI 2.02-3.75). The authors determined that to avoid one case of UI, 8–9 cesarean sections are needed. There was no difference between acute and elective cesarean sections. The present study demonstrates that obstetric exposure influences the development of pelvic floor disorders. Its strengths lie in its comprehensive data collection by the use of a national birth registrar, as well as a high (65.2 %) survey response rate. However, lack of a comparison with a control group of nulliparous women with UI and the use of a non-validated questionnaire without assessment of the impact of UI on quality of life are both limitations. From the results of this study, it appears that choosing a vaginal delivery is more likely to result in urinary incontinence compared with cesarean section. Before we conclude that cesarean section protects against the development of pelvic floor disorders, we should remember that with a retrospective study only an association between the exposure and the outcome can be made. A cause and effect relationship cannot be inferred as other lifetime exposures affecting the development of UI such as medical co-morbidities (diabetes, neurological disorders), chronic constipation, and chronic cough cannot be excluded