Courtenay Moore

Single-Port Laparoscopic Surgery in Urology: Initial Experience

OBJECTIVES To present our initial experience with single-port laparoscopic urologic surgery using the Uni-X Single Port Access Laparoscopic System, a single port, multichannel cannula, with specially designed curved laparoscopic instrumentation. METHODS We performed single-port laparoscopic surgery in 10 patients, including renal cryotherapy in 4, wedge kidney biopsy in 1, radical nephrectomy in 1, and abdominal sacrocolpopexy in 4. For the transperitoneal approach, the multichannel port was inserted transumbilically, and for retroperitoneoscopy, the port was inserted at the tip of the 12th rib. Data were collected prospectively into our institutional review board-approved data registry. RESULTS Since September 25, 2007, a total of 10 patients have undergone single-port laparoscopic surgery for various upper abdominal and pelvic pathologic findings. All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time for the various kidney procedures was 2.5 hours (range 2 to 3.2) and was 2.5 hours (range 2 to 3) for sacrocolpopexy. The mean blood loss was 100 mL for the renal procedures and 90 mL for sacrocolpopexy. The hospital stay was 2.8 days (range 1 to 8) for the kidney procedures and 2 days for sacrocolpopexy. One complication occurred in a patient with baseline congestive heart failure who underwent cryoablation and required oxygen mask ventilation postoperatively that delayed her hospital discharge for 1 week. The same patient, who was anemic preoperatively, was transfused with 3 U of packed red blood cells, although the postoperative computed tomography scan revealed a small perinephric hematoma. CONCLUSIONS Single-port laparoscopic renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy are safe and feasible. Additional experience and continued investigation are warranted.

Robotic abdominal sacrocolpopexy/sacrouteropexy repair of advanced female pelvic organ prolaspe (POP): utilizing POP‐quantification‐based staging and outcomes

Associate Editor

NOTES Transvaginal Nephrectomy: First Human Experience

OBJECTIVES To present the operative outcomes of the first natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy. METHODS A 57-year-old woman with hypertension, right-sided flank pain, and radiographic evidence of an atrophic right kidney consented for NOTES transvaginal nephrectomy. Pneumoperitoneum was achieved with a Veress needle inserted deep in the umbilicus. Under direct vision, a colpotomy was made and a transvaginal port positioned. Using standard and articulating operating instruments inserted transvaginally, the kidney was mobilized and the renal hilum was controlled with an endovascular stapler. The kidney was placed in a laparoscopic retrieval bag and extracted through the vaginal incision. Salient demographic and operative data were obtained. RESULTS NOTES transvaginal nephrectomy was successfully completed, with all the operative steps performed transvaginally. Dense pelvic adhesions from a prior hysterectomy necessitated the use of a 5-mm umbilical port during vaginal port placement and for retraction of the ascending colon during division of the renal hilum. No intraoperative complications occurred. Operative time was 307 minutes, with 124 minutes dedicated to vaginal port placement and 183 minutes dedicated to adhesiolysis and nephrectomy. The duration of hospitalization was 23 hours. The visual analog pain scale score was 1 of 10 on postoperative day 2. CONCLUSIONS Our experience shows that NOTES transvaginal nephrectomy is technically feasible. Access to the peritoneal cavity should be performed under visual guidance and after insufflation through the umbilicus. Additional experience is needed to better define patient selection criteria and indications for NOTES transvaginal urologic surgery.

Purely Transvaginal/Perineal Management of Complications From Commercial Prolapse Kits Using a New Prostheses/Grafts Complication Classification System

PURPOSE Commercial prolapse mesh kits are increasingly used in the management of pelvic organ prolapse. We present our experience with the transvaginal/perineal management of synthetic mesh related complications from prolapse kits. In addition, we used the new ICS/IUGA (International Continence Society/International Urogynecological Association) prostheses/grafts complication classification system to report on our contemporary series. MATERIALS AND METHODS A retrospective chart review of all patients who underwent surgical removal of transvaginal mesh for mesh related complications after prolapse kit use from November 2006 to April 2010 at 1 institution was performed. We report our contemporary series of mesh complications using the new ICS/IUGA prostheses/grafts complication classification system. Postoperative pain, degree of improvement and presence of continued symptoms were reported by patients at last followup. RESULTS A total of 23 patients underwent transvaginal removal of mesh during the study period. Mean patient age was 61 years. Median period of latency to mesh related complication was 10 months (range 1 to 27). Indications for mesh removal included vaginal/pelvic pain (39%), dyspareunia (39%), vaginal mesh extrusion/exposure (26%), urinary incontinence (35%), recurrent pelvic organ prolapse (22%), bladder mesh perforation with recurrent urinary tract infection (22%), rectal mesh perforation (4%), ureteral perforation injury (4%), retained foreign body (surgical sponge) in the bladder (4%) and vesicovaginal fistula (9%), with most patients citing more than 1 reason. CONCLUSIONS Although technically difficult in some cases, purely transvaginal mesh excision appears to be safe with resolution of almost all presenting symptoms. Although slightly cumbersome, the new ICS/IUGA prostheses/graft complication classification system can be used to report and more accurately characterize mesh complications.

Single-port Laparoscopic Abdominal Sacral Colpopexy: Initial Experience and Comparative Outcomes

OBJECTIVES To determine the efficacy and safety of single-port laparoscopic abdominal sacral colpopexy (ASC) for the treatment of female pelvic organ prolapse (POP). METHODS A retrospective cohort study was performed to assess perioperative outcomes among women who were treated for symptomatic POP with laparoscopic, robotic, or single-port laparoscopic ASC. All patients underwent preoperative history and physical examination including POP quantification (POP-Q) staging and urodynamics. ASC with or without anti-incontinence surgery was performed via the aforementioned approaches. Demographic and perioperative data were obtained. Patients were followed up postoperatively at 3 and 6 months with POP-Q evaluation. Statistical analysis was performed. RESULTS From October 2005 to July 2008, 30 female patients with symptomatic Stage II (6 patients), Stage III (23 patients), or Stage IV (1 patient) POP were treated with laparoscopic (10), robotic (10), or single-port laparoscopic (10) ASC. Mean age of the entire cohort was 61.1 years. Mean body mass index was 26.7 kg/m(2). Seventeen patients demonstrated stress urinary incontinence and underwent concomitant sling placement. No intraoperative complications were encountered. No significant difference was noted in the 3 cohorts with respect to operative time, blood loss, mean visual analog pain score at discharge, or duration of hospitalization. At 6 months following surgery, 27 patients underwent follow-up POP-Q, with all patients demonstrating excellent apical support and prolapse reduction. CONCLUSIONS Single-port laparoscopic ASC offers comparable efficacy and superior cosmesis compared to alternative approaches. Long-term follow-up is needed to confirm durability of repair.

Surgically Corrected Urethral Diverticula: Long-term Voiding Dysfunction and Reoperation Rates

OBJECTIVES To present the largest reported cohort of women with urethral diverticula and to evaluate the surgical outcomes and long-term voiding symptoms after urethral diverticulectomy. Studies evaluating the outcomes after urethral diverticulectomy have been limited by small patient numbers and short-term follow-up. METHODS Women who had undergone diverticulectomy at our institution from 1996 to 2008 were mailed surveys. Urinary bother was assessed using the Urogenital Distress Inventory 6-item questionnaire, and patients were asked to report subsequent urethral or vaginal surgery and the number of urinary tract infections within the previous year. To determine the rate of surgical recurrence, the charts of women not responding to the survey were reviewed. RESULTS A total of 122 women were identified as having undergone urethral diverticulectomy during the study period. Of these, 13 (10.7%) had an eventual recurrence that required repeat surgical excision. Patients with a proximal diverticulum, multiple diverticula, or previous pelvic or vaginal surgery (excluding previous diverticulectomy) were more likely to develop recurrence (P = .01, P = .03, and P < .001, respectively). For the 61 women (50%) responding to our survey, the mean follow-up was 50.4 months. Of these 61 women, 24 (39.3%) had had a urinary tract infection within the previous year, with 14 (23%) women having had ≥3 within the previous year. Also, 16 (26.2%) had persistent pain or discomfort with urination. The mean ± SD total Urogenital Distress Inventory-6 score was 31.1 ± 25.5 for the survey responders. CONCLUSIONS To our knowledge, our study represents the largest study with the longest follow-up after urethral diverticulectomy. Patients with proximal or multiple diverticula and those with previous pelvic surgery should be counseled appropriately regarding the risks of recurrence and persistent voiding dysfunction.

Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse.

Due to the anatomic proximity of the urinary and genital tracts, iatrogenic ureteral injury during pelvic organ prolapse repairs is a serious complication that we have managed in increasing number at our institution. However, few centers have reported on their experience with ureteric injuries associated with gynecologic reconstructive surgery. These ureteral injuries may lead to much morbidity, in particular the formation of ureterovaginal fistula, and the potential loss of renal function especially when diagnosed postoperatively. It is necessary, therefore, for surgeons to have a thorough knowledge of ureteral anatomy and to take precautions to prevent such injuries. The purpose of this article is to review this pertinent anatomy and the key principles of management of ureteric complications of transvaginal surgery for pelvic organ prolapse. The present study illustrates the application of our treatment algorithm based on the time of presentation and the patient condition.

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long‐term extension study

To present final efficacy/safety results from a prospective, long‐term extension trial of onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO); patients received treatment for up to 4 years.

Advancing the understanding of pathophysiological rationale for the treatment of stress urinary incontinence in women: the 'trampoline theory'.

The physiological factors involved in urinary continence comprise both central and peripheral control mechanisms. The central control mechanisms include input from the cerebral cortex, midbrain, thoracic and sacral spinal cord through the autonomic and somatic innervation of the lower urinary tract organs. The peripheral control mechanisms involve organs (bladder, urethra), muscles and bony supporting structures. Urinary continence is the result of a complex and fascinating co-ordination between the central and peripheral mechanisms. In women, urinary continence during stress (elevations in intra-abdominal pressure) is maintained by several mechanisms. First, there is passive transmission of abdominal pressure to the proximal urethra. A guarding reflex, involving an active contraction of striated muscle of the external urethral sphincter, can transiently help continence [5,6], but the abdominal pressure transmitted to the proximal urethra does not account entirely for the increase in urethral pressure [7]. Abdominal pressure is also transmitted through the proximal urethra pressing the anterior wall against the posterior wall. The posterior wall remains rigid if there is adequate pelvic support from muscle and connective tissues. During voiding, the pubourethral ligaments and vaginal connections to the pelvic muscles and fasciae actively change the position of the bladder neck and proximal urethra. These attachments contain both fascia and smooth muscle [8]. This change compresses the urethra against the pubis during bladder filling and straining. Thus, urinary continence results from a combination of passive anatomical coaptation and active muscle tone.

Improved Sexual and Urinary Function in Women with Sacral Nerve Stimulation

Objectives:  Urinary and sexual function improve following sacral nerve stimulation (SNS) for refractory overactive bladder. No significant associations between these changes have been found. Whether improvements in sexual function are independent of or secondary to improvements in urinary function remains unclear. The aim of this study was to analyze changes in urinary and sexual function in a homogeneous sample of patients undergoing SNS for urge urinary incontinence and subsequently identify associations between the two.