Arvind Vashisht

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.

New procedures for uterine prolapse

Traditionally, vaginal hysterectomy and Manchester repair were the surgical approaches to treating uterine prolapse; however, both are associated with a relatively high subsequent vaginal vault recurrence. Laparoscopic uterine suspension is a new way of maintaining uterine support. Many women are keen to keep their uterus for a variety of reasons, including maintaining reproductive capability and the belief that the uterus, cervix, or both, may play a part of their gender identity. Non-removal of the uterus may retain functional (e.g. bowel, bladder and sexual) benefits. Therefore, the concept of uterine preservation for pelvic-organ prolapse has been of interest to pelvic-floor surgeons for many decades. In this review, we provide an overview of the available evidence on treating uterine prolapse surgically. We describe techniques to support the vault during hysterectomy, and examine the evidence for uterine-sparing surgery. Comparative outcomes for vaginal, abdominal and laparoscopic routes will be made.

Laparoscopic Sacrocolpopexy to Treat Prolapse of the Neovagina Created by Vaginal Dilation in Rokitansky Syndrome

BACKGROUND Vaginal dilation is the first choice of treatment for women with a short vagina due to Rokitansky syndrome. Although the neovagina lacks pelvic support, prolapse of the neovagina is a surprisingly rare complication of treatment. Laparoscopic sacrocolpopexy is recommended in the treatment of posthysterectomy vault prolapse in younger women but has not been used to treat neovaginal prolapse. CASE A 23-year-old woman with Rokitansky syndrome presented with a symptomatic prolapse of the neovagina. This was successfully treated with a laparoscopic sacrocolpopexy. SUMMARY AND CONCLUSIONS Laparosopic sacrocolpopexy appears to be an effective treatment in the unusual situation of vaginal prolapse after dilation.

Diathermy-induced injury may affect detection of occult tubal lesions at risk-reducing salpingo-oophorectomy.

Background Electrosurgery-induced tubal thermal injury obscures cellular detail and hampers histomorphological assessment for occult pathology. Objective The objectives of this study were to report on diathermy-related thermal injuries to the fallopian tube observed at RRSO and explore its potential impact on the detection of occult tubal epithelial lesions. Design This study was composed of high-risk women from breast and/or ovarian cancer families attending a tertiary high-risk familial gynecologic cancer clinic. This was a retrospective case-control analysis of high-risk women who underwent RRSO. Cases were all women detected to have occult lesions (tubal atypia/carcinoma in situ/cancer) between January 2005 and December 2010. Control subjects were all women with normal tubal/ovarian histology between August 2006 and December 2007. Methods Two pathologists performed histopathologic assessment for grade of thermal injury. Tubal diathermy injury rates were compared between cases and controls. Statistical analysis was undertaken using SPSS version 18. The Mann-Whitney U test compared age distributions; &khgr;2/Fisher tests, the difference between proportions, and &ggr; test, the difference in ordinal variables between the groups. Results A novel tubal thermal index to describe the severity of injury is reported. Lack of fimbrial thermal injury is twice as likely (odds ratio, 2.04; 95% confidence interval, 1.06–3.92) to be associated with detection of occult tubal pathology, whereas isthmic injury does not affect detection rate (P = 0.744). The groups were comparable with respect to age at RRSO (P = 0.531) and the presence of BRCA mutations (P = 0.192). Conclusions This report highlights the potential impact of electrosurgical thermal injury on detection of occult tubal pathology following RRSO. It is important for surgeons to avoid thermal injury to the distal end of the tube.

The new laparoscopic uterine sling suspension procedure: first year follow-up data

Ideally, any uterine conservation procedure for the treatment of prolapse should be effective, and yet, not significantly jeopardise subsequent surgery should a hysterectomy become a necessity in the future. We present our 1-year data on the new laparoscopic uterine sling suspension procedure. We have found significant anatomical improvements in points C and D on the pelvic organ prolapse quantification score, and improvements in vaginal, sexual and quality of life scores. We conclude that this technique is a promising new surgical method for treating uterine prolapse.

Voiding dysfunction in women undergoing laparoscopic treatment for moderate to severe endometriosis.

We conducted a prospective study to evaluate the incidence and the surgical factors determining the development of postoperative voiding dysfunction following this surgery. The presence of rectovaginal dissection was significantly associated with the development of voiding dysfunction, and we suggest vigilance among practitioners about the possibility of the development of voiding dysfunction in this group of women.

Laparoscopy in urogynaecology

Laparoscopic surgery has the potential to further develop urogynaecological surgery. Laparoscopic urogynaecological surgery allows improved visualisation of pelvic organs, reduced postoperative pain, shorter admission and a quicker return to activities of daily living. There is growing interest in new treatments for prolapse with the advent of operations enabling uterine conservation, and a revival in abdominal vaginal vault procedures and colposuspensions. Operative laparoscopy requires a high degree of technical skill and training. It is difficult for trainees to universally gain good exposure to higher laparoscopic training.

SINGLE CENTRE RANDOMISED PILOT STUDY OF TWO REGIMENS (30 MINS DAILY OR 30 MINS WEEKLY FOR 12 WEEKS) OF TRANSCUTANEOUS TIBIAL NERVE STIMULATION USING A NOVEL DEVICE FOR TREATING MULTIPLE SCLEROSIS-RELATED OVERACTIVE BLADDER SYMPTOMS

Introduction Percutaneous tibial nerve stimulation (PTNS) is effective for managing multiple sclerosis (MS)-related overactive bladder (OAB) symptoms. However the need for weekly clinic visits restricts its use. The purpose of this study was to evaluate safety and efficacy of a novel, self-applying device for managing OAB symptoms. Study design, materials and methods 48 patients reporting OAB (MS n=24, idiopathic n=24), were randomized (1:1) to either daily or weekly treatments for 12 weeks with geko™, a novel device stimulating the tibial nerve transcutaneously. Efficacy was assessed using validated questionnaires (ICIQ-OAB, ICIQLUTS-QoL) and bladder diaries filled at weeks 4, 8, and 12. Urinary neurotrophins (Nerve growth factor (NGF) and Brain derived neurotrophic factor) were measured. Results 34 patients (MS n=19) completed the study. 18 patients responded to treatment (53%); 72% of responders belonged to the MS cohort. Multilevel regression analysis suggested significant improvements in questionnaire scores (ICIQ-OAB –10.2 (–13.5 to –6.9; p=0.001), ICIQLUTS-QOL –40.8 (–57.4 to –24.3; p=0.000)), without differences between weekly and daily-treated arms. No significant adverse effects were reported and patients rated the treatment as easy to use and comfortable. NGF levels at baseline were significantly greater in non-responders (p=0.05). Concluding message In this pilot study, a patch device suitable for self-application at home appears to be an effective, safe and convenient alternative for managing MS-related OAB symptoms.