Babak Vakili

Primary Amenorrhea with an Abdominal Mass at the Umbilicus

BACKGROUND Transverse vaginal septum is a rare cause of primary amenorrhea. It has a reported incidence of 1:2,100-1:72,000 and a variety of clinical presentations. CASE A 16-year-old patient presented with primary amenorrhea and a large abdominal mass that was palpated on clinical exam and confirmed on MRI imaging. A diagnosis of transverse vaginal septum was ultimately made and the patient underwent a successful surgical excision of the septum and vaginal reconstruction. CONCLUSION The presentation, etiology, diagnosis, and surgical treatment of a transverse vaginal septum are discussed.

Use of synthetic mesh to prevent recurrent vaginal evisceration: a case report

Vaginal evisceration of the bowel is a rare and life-threatening complication of gynecologic surgery; recurrence is even more rare. Most cases in the literature discuss primary closure of the dehisced vaginal cuff with delayed absorbable sutures via a vaginal, abdominal, or laparoscopic approach. The case presented here is of a patient who had a history of recurrent vaginal evisceration treated with an abdominal sacrocolpopexy utilizing synthetic mesh. Further recurrence, to date, has been prevented.

Hydrodistention of the bladder for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC)

The purpose of this study is to determine whether a transvaginal trigonal block immediately preceding cystoscopy with hydrodistention yields an additional therapeutic benefit compared to cystoscopy with hydrodistention alone for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC).

Risk factors for vaginal mesh exposure after mesh-augmented anterior repair: a retrospective cohort study.

Objectives The aim of this study is to identify risk factors for vaginal mesh exposure after mesh-augmented repair of anterior prolapse. Methods We performed a retrospective cohort study of all patients who had mesh-augmented anterior repair by 1 surgeon between January 2007 and February 2012. Data were extracted from medical records. The primary outcome was the rate of anterior or apical vaginal mesh exposure. Both univariate and multivariate analyses were performed. Results A total of 201 subjects were included. The mean (SD) follow-up was 14.3 (12.4) months. All cases were done using a type 1 macroporous monofilament polypropylene mesh. The overall mesh exposure rate was 8.5% (17/201). Univariate analysis showed a statistically significant positive association between exposure rates and the following risk factors: lower body mass index (BMI) (P = 0.016), menopause in combination with the use of hormone replacement therapy (P = 0.023), midline sagittal vaginal incision (compared with distal transverse incision) (P = 0.026), concurrent total hysterectomy (P < 0.001), surgery time (P = 0.002), and worse apical prolapse at baseline (P = 0.007). After multivariate analysis using logistic regression, only BMI (P < 0.001) and concomitant total hysterectomy (odds ratio, 48; P < 0.001) remained relevant. The exposure rate was 23.5% (16/68) when concomitant hysterectomy was performed compared with 0.8% (1/133) when no hysterectomy was done. Exposure rates stratified by BMI class were 12.9% (8/62) for BMI less than 25 kg/m2, 9.5% (8/84) for BMI of 25 to 29.9 kg/m2, 3.1% (1/32) for BMI of 30 to 34.9 kg/m2, and 0% (0/23) for BMI greater than or equal to 35 kg/m2. Conclusions Concomitant total hysterectomy is an independent risk factor for mesh exposure after mesh-augmented anterior repair, whereas BMI may negatively correlate with exposure rates.

Surgical Outcomes of Paravaginal Repair After Robotic Sacrocolpopexy

STUDY OBJECTIVE To evaluate surgical outcomes of robotic sacrocolpopexy with and without paravaginal repair for pelvic organ prolapse (POP). DESIGN A retrospective cohort study with a 3-month postoperative follow-up (Canadian Task Force classification II-3). SETTING An academic-affiliated community hospital with a practice comprised of 3 surgeons board certified in female pelvic medicine and reconstructive surgery. PATIENTS Patients undergoing robotic sacrocolpopexy for POP from April 2013 through November 2014. INTERVENTIONS Robotic paravaginal repair (RPVR) after robotic sacrocolpopexy. The decision to perform a paravaginal repair was at the discretion of the surgeon. MEASUREMENTS AND MAIN RESULTS One hundred fifty-six patients underwent a robotic sacrocolpopexy. Twenty-four patients were excluded because of a lack of a 3-month postoperative follow-up. Nine patients underwent concomitant vaginal paravaginal repair and were also excluded. Outcomes were defined by comparing preoperative characteristics with those at the 3-month follow-up. Of the 123 patients in this cohort, 21 patients underwent a concomitant RPVR, and 102 did not. All Pelvic Organ Prolapse Questionnaire (POP-Q) points improved within groups (p < .001) except for the total vaginal length (TVL) in the RPVR group (p = .940). The Patient Global Impression of Improvement (PGI-I) did not differ between groups (1.2 vs 1.5, p = .128). Subgroup analysis was performed on patients with preoperative anterior wall prolapse of stage 3 or greater. Baseline characteristics and perioperative data were not remarkably different from the main cohort. All POP-Q points improved within groups (p < .001) except for the TVL in the RPVR group (p = .572). The PGI-I did not differ between groups (1.2 vs 1.3, p = .378). CONCLUSION In both groups, anatomic markers substantially improved within each group. There were significant differences in postoperative POP-Q findings, which may have been influenced by the fact that patients undergoing RPVR usually had worse baseline prolapse. This selection bias creates difficulty with interpretation. Although in this study RPVR did not change subjective outcomes, further study is necessary to control for the severity of prolapse.

Estimation of Uterine Size: How Accurate Are We?

Objective To evaluate the accuracy of gynecologic surgeons at estimating uterine dimensions and weight. Methods Six model uteri of various sizes were created to simulate the size and consistency of a uterus and displayed at 3 stations. The visual station (VS) comprised 2 specimens placed on an unmarked table. The laparoscopic station (LS) consisted of 2 model uteri, each placed in a separate simulated abdomen with a 0 degree laparoscope and 2 operative trocars with standard instruments. The blind weight station (BWS) consisted of blind palpation of 2 separately weighted models (heavy model [HM] and light model [LM]). Participants visually estimated the dimensions of each VS and LS models and blindly palpated the BWS models to estimate weight. Results Participants included 15 residents, 27 attendings, and 6 medical students. There was no difference in estimation accuracy regarding gender and age. For the VS and LS groups, participants underestimated all dimensions (VS variance = −15.0%; P < 0.001 and LS variance = −31.9%; P < 0.0001). Laparoscopic estimation was less accurate than direct vision (P < 0.0001). Attendings and residents equally underestimated the 3 dimensions visually (P = 0.46), but attendings were more accurate at estimating laparoscopic dimensions (−25.8% vs −41.1%; P = 0.0001). All groups overestimated model weights (HM variance, 92.5%; P < 0.001 and LM variance, 132.0%; P < 0.0001), with attendings more accurate than residents (39.7% vs 167.6%; P = 0.015 for HM and 52.0% vs 238.5%; P = 0.035 for LM). Conclusions Gynecologic surgeons at all levels of training are inaccurate at estimating dimensions and weights. With surgical decisions often predicated on estimates, education is needed to improve estimation methods.

Surgical Outcomes of Paravaginal Repair Following Robotic Sacrocolpopexy

Study Objective: To determine if peritoneal washings of the abdominopelvic cavity during laparoscopic myomectomy can detect leiomyoma cells after power morcellation. Design: Pilot prospective cohort study. Setting: University of North Carolina Hospitals, an academic, tertiary referral center. Patients: Patients undergoing laparoscopic or robotic myomectomy for suspected benign leiomyoma by members of the Minimally Invasive Gynecologic Surgery division, September 2014-January 2015. Intervention: Washings of the peritoneal cavity were collected at three times during surgery: (1) the beginning of the procedure once the peritoneal cavity has been accessed laparoscopically, (2) after the myoma has been excised and myometrial incision closed, and (3) following uncontained power morcellation. Measurements and Main Results: Ten patients were recruited. The median age was 36 years and the median BMI was 25 kg/m2. The median morcellation time was 18.5 minutes (range 2–36). In all cases, pathology was consistent with benign leiomyomata. The median specimen weight was 301 grams (range 50–935). Cytologic evaluation using ThinPrep (Hologic, Bedford MA) with Papanicolaou staining did not detect any smooth muscle cells. Cell block histology, however, detected spindle cells on four post-morcellation samples (time 3). Two of these four samples also had spindle cells detected on the post-myomectomy closure samples (time 2). Desmin and smooth muscle actin immunostaining performed on these four samples were positive, confirming the presence of smooth muscle cells in the samples after morcellation. Conclusion: Collecting peritoneal washings is a simple method that could potentially detect leiomyoma cells after power morcellation. Performing cell blocks seems to be necessary to detect the smooth muscle cells as ThinPrep cytology failed to identify smooth muscle cells when present. A quantitative measure of tissue dissemination would allow future researchers test comparative safety of new morcellation methods.

ORAL POSTER 1: Outcomes of Vaginal Reconstructive Surgery With and Without Graft Material

OBJECTIVE This study was undertaken to evaluate the outcomes of vaginal surgery for pelvic organ prolapse, comparing cases implementing graft augmentation to those without graft augmentation. STUDY DESIGN This was a retrospective cohort study of 312 patients who underwent vaginal surgery for prolapse from February 1998 to January 2004. RESULTS Of the 312 patients, 98 (31.4%) had graft augmentation. The median follow-up was 9 months (3-67 months). Graft use was not associated with reduction in recurrent prolapse, recurrent stage 3 prolapse, recurrent incontinence, or additional surgery for prolapse. After controlling for confounders, there was still no difference in surgical outcomes. Complications such as vaginal/graft infection (18.4% vs 4.7%; P < .001) and granulation tissue (38.8% vs 17.3%; P < .001) were more common after cases in which graft was used. CONCLUSION In the early postoperative period, there was no benefit in using graft for prolapse repair. Graft use leads to a higher rate of postoperative complications.