Alfred Cutner

Abdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series

Objectives  To audit the clinical outcome of abdominal vault suspension (sacrocolpopexy, hysteropexy or cervicopexy) using non‐absorbable mesh, without burial by closure of the peritoneum.

Laparoscopic vaginoplasty: alternative techniques in vaginal reconstruction

Construction of a neovagina is the next step for women with an absent vagina who have failed vaginal dilator therapy. Traditional operative techniques such as skin grafting or intestinal substitution have major disadvantages including prolonged recovery time and significant scarring. Laparoscopic vaginoplasty is performed widely throughout Europe but has not been available in the UK until now. We report on five women who underwent laparoscopic vaginoplasty. Three women underwent a laparoscopic Vecchietti procedure and two underwent a laparoscopic Davydov procedure. Details were recorded on preoperative features, perioperative problems and early postoperative outcome. Laparoscopic vaginoplasty is a safe treatment for vaginal agenesis, and short‐term results are encouraging.

Total laparoscopic hysterectomy as a primary surgical treatment for endometrial cancer in morbidly obese women

To evaluate the feasibility of total laparoscopic hysterectomy as the primary treatment for endometrial cancer in morbidly obese women, an audit was carried out during an 18‐month period in a tertiary referral centre for gynaecological oncology. Four women who had laparoscopic surgery were compared with a similar cohort who had open surgery. The mean operating time was equivalent, without evidence of excess morbidity with the laparoscopic approach. However, inpatient stay was longer with open versus laparoscopic surgery (11.5 vs 4 days). Laparoscopic surgery is safe to use in morbidly obese women with endometrial cancer.

Value of transvaginal ultrasound in assessing severity of pelvic endometriosis

The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis.

Assessment of urinary symptoms in early pregnancy.

Objectives— To determine the correlation between lower urinary tract symptoms and urodynamic findings in early pregnancy.

Ultrasound mapping of pelvic endometriosis: does the location and number of lesions affect the diagnostic accuracy? A multicentre diagnostic accuracy study.

BackgroundEndometriosis is a common condition which causes pain and reduced fertility. Treatment can be difficult, especially for severe disease, and an accurate preoperative assessment would greatly help in the managment of these patients. The objective of this study is to assess the accuracy of pre-operative transvaginal ultrasound scanning (TVS) in identifying the specific features of pelvic endometriosis and pelvic adhesions in comparison with laparoscopy.MethodsConsecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. They all underwent a systematic transvaginal ultrasound examination in order to identify discrete endometriotic lesions and pelvic adhesions. The accuracy of ultrasound diagnosis was determined by comparing pre-operative ultrasound to laparoscopy findings.Results198 women who underwent preoperative TVS and laparoscopy were included in the final analysis. At laparoscopy 126/198 (63.6%) women had evidence of pelvic endometriosis. 28/126 (22.8%) of them had endometriosis in a single location whilst the remaining 98/126 (77.2%) had endometriosis in two or more locations. Positive likelihood ratios (LR+) for the ultrasound diagnosis of ovarian endometriomas, moderate or severe ovarian adhesions, pouch of Douglas adhesions, and bladder deeply infiltrating endometriosis (DIE), recto-sigmoid colon DIE, rectovaginal DIE, uterovesical fold DIE and uterosacral ligament DIE were >10, whilst for pelvic side wall DIE and any ovarian adhesions the + LH was 8.421 and 9.81 respectively.The negative likelihood ratio (LR-) was: <0.1 for bladder DIE; 0.1-0.2 for ovarian endometriomas, moderate or severe ovarian adhesions, and pouch of Douglas adhesions; 0.5-1 for rectovaginal, uterovesical fold, pelvic side wall and uterosacral ligament DIE. The accuracy of TVS for the diagnosis of both total number of endometriotic lesions and DIE lesions significantly improved with increasing total number of lesions.ConclusionsOur study has shown that the TVS diagnosis of endometriotic lesion is very specific and false positive results are rare. Negative findings are less reliable and women with significant symptoms may still benefit from further investigation even if TVS findings are normal. The accuracy of ultrasound diagnosis is significantly affected by the location and number of endometriotic lesions.

Laparoscopic uterine sling suspension: a new technique of uterine suspension in women desiring surgical management of uterine prolapse with uterine conservation

The surgical management of uterine prolapse in women who wish to retain their uterus remains a challenge. Several techniques have been reported using open abdominal, laparoscopic and vaginal approaches. The laparoscopic approach offers both excellent intraoperative visualisation of supportive and adjacent structures and quick postoperative recovery. Currently, laparoscopic suspension of the uterus to the round ligaments, uterosacral ligaments, suture and synthetic mesh suspension to the sacral promontory have been reported. This report describes a new surgical technique of laparoscopic uterine suspension, which has been performed successfully in eight women. Mersilene tape is used to suspend the uterus to the sacral promontory bilaterally and to recreate new uterosacral ligaments.

A new technique of laparoscopic ovariopexy before irradiation

OBJECTIVE To report a new technique of laparoscopic ovarian transposition to preserve ovarian function in women who require pelvic irradiation for musculoaponeurotic fibromatosis (extra abdominal desmoid). DESIGN Case report. SETTING University teaching hospital. PATIENT(S) Two nulliparous women who required adjunctive radiotherapy for musculoaponeurotic fibromatosis where radiotherapy planning indicated that the right ovary could be removed from the field of radiation by anterior transposition. INTERVENTION(S) Laparoscopic suturing of the right ovary to the right round ligament with intracorporeal polypropylene sutures. MAIN OUTCOME MEASURE(S) Technical feasibility, recovery, postoperative adhesions, ease of ovarian repositioning, and evidence of ovulation after completion of radiotherapy. RESULT(S) The technique was easily performed without needing to divide the ligament of the ovary. Recovery was rapid, and there were no postoperative adhesions. The ovary showed evidence of continued function and was easily repositioned by dividing the sutures. CONCLUSION(S) In selected cases, this method of ovarian transposition has the advantages not only of being technically easy but also of allowing for repositioning of the ovary with minimal disruption of its anatomical relationship to the fallopian tube, thereby favoring fertility.

Surgical approaches to treating vaginal agenesis

UCL Institute of Women’s Health, Elizabeth Garrett Anderson and Obstetric Hospital, Huntley Street, London, WC1E 6DH, UKCorrespondence: Miss SM Creighton, UCL Institute of Women’s Health, Elizabeth Garrett Anderson and Obstetric Hospital, Huntley Street,London UKWC1E 6DH, UK. Email sarah.creighton@uclh.nhs.ukAccepted 12 September 2007.

Lower urinary tract symptoms in early pregnancy

SummaryTwo hundred and fifty-six women were questioned regarding their lower urinary tract symptoms in early pregnancy. In addition 44 completed frequency charts and 30 measured their fluid intake and urine output. We found that increased voiding occurred in early pregnancy in 91 per cent of women. Black women suffered less diurnal frequency but worse nocturia than white women. Nocturia appeared to be caused by a decreased functional bladder capacity and increased number of hours spent asleep. With respect to stress incontinence, we found a greater prevalence in white parous women compared to white nulliparous women but there was no such difference in the black group.