David Sheyn

Laparoendoscopic single-site surgery for benign ovarian cystectomies

Background: Single-port laparoscopy (LESS) utilizes a single, multichannel port in an attempt to decrease postoperative pain, while enhancing cosmesis and minimizing the potential risks and morbidities associated with the multiple ports used in conventional laparoscopy. Methods: We performed a retrospective study examining three tertiary care referral centers. From September 2009 until March 2013, 31 patients with ovarian cystic lesions were treated using the LESS technique. A control group of 57 patients who underwent conventional laparoscopic ovarian cystectomy was included for comparison. Results: All patients underwent a technically successful cystectomy. There were no statistically significant differences in the mean operative time or estimated blood loss between the two groups. Narcotic use during the recovery period was reported in less patients in the LESS group than in the laparoscopic group (p = 0.05). Conclusions: The LESS technique can be used to safely perform cystectomies on women with benign ovarian cysts. Additional investigation is needed to evaluate the safety, cost-effectiveness and long-term outcomes of this new approach.

Multidisciplinary approach for management of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome and rectal prolapse

Introduction and hypothesisMüllerian duct anomalies are frequently associated with congenital anomalies of other organ systems, and in particular, the urinary system. A multidisciplinary approach is often required for successful diagnosis and surgical management of complex pelvic anomalies. The objective of this video is to provide a guide for diagnosis of complex female pelvic anomalies and robotic-assisted approach to surgical management with a multidisciplinary team of surgeons.MethodsThe patient presented is a 24-year-old nulligravida with obstructed hemivagina and ipsilateral renal dysplasia, ipsilateral ectopic ureter, and rectal prolapse. This video outlines the methods used to obtain the correct diagnosis and steps for successful treatment using a robotically assisted surgical approach.ResultsComplex Müllerian anomalies involving multiple organ systems may require the use of advanced three-dimensional imaging to achieve the correct diagnosis, and a minimally invasive surgical approach with robotic assistance is an effective strategy for management.ConclusionsA multidisciplinary approach is often required to successfully diagnose and treat women with complex Müllerian anomalies.

LeFort colpocleisis: a step-by-step simulation video for Female Pelvic Surgeons

Introduction and hypothesisLeFort colpocleisis is a minimally invasive surgical option for patients with pelvic organ prolapse who no longer desire sexual activity. Pelvic surgeons have limited exposure to this procedure during their training, and are therefore less likely to offer this procedure to their patients.MethodsWe use a split screen live action surgery, side by side with a low cost 3D model of a prolapse to describe a LeFort colpocleisis step by step.ResultsThis video is an easily reproducible guide to the steps and surgical techniques necessary to successfully perform a LeFort colpocleisis. The simulation model can be used to educate and train those performing female pelvic surgery.ConclusionPelvic surgeons should be able to offer LeFort colpocleisis to their patients. This video may be used to facilitate the understanding and reproducibility of the procedure.

Transvaginal bladder-neck closure: a step-by-step video for female pelvic surgeons

Introduction and hypothesisTransvaginal bladder-neck closure is a definitive surgical option for urethral erosion due chronic bladder catheterization in patients with neurogenic bladder. Surgeons who perform female pelvic reconstructive surgery have limited exposure to this procedure in their training. The purpose of this video is to demonstrate a transvaginal bladder-neck closure due to urethral erosion in a patient with neurogenic bladder due to persistent neuropathy from Guillain-Barré syndrome managed with prolonged catheter drainage.MethodsWe used a live-action surgical demonstration to describe transvaginal bladder-neck closure with urinary diversion.ResultsThis video provides a step-by-step approach to transvaginal bladder-neck closure as treatment for urethral erosion from chronic catheterization. This video can be used to educate and train those performing female pelvic reconstructive surgery.ConclusionsSurgeons who perform female pelvic surgery should be familiar with the complications of chronic Foley catheterization and treatment options that include transvaginal bladder-neck closure. This video may be used to facilitate reproducibility and comprehension of this procedure.

National survey of urogynecological practice patterns among United States OB/GYN oral board examinees in different practice settings

Introduction and hypothesisThe current urogynecological surgical experience of recent OB/GYN graduates in different practice settings is unclear. The aim of this study was to evaluate differences in urogynecological surgical care between private practitioners (PPs) and other generalist OB/GYN oral board examinees.MethodsA total of 699 OB/GYN oral board examination examinees were administered a survey during board preparatory courses with a 70.7% response rate. The primary outcome was to determine differences in subjective reported performance of urogynecological surgery with and without apical support procedures (female pelvic medicine and reconstructive surgery, FPMRS, ± apical) between PP and generalists in other practice models (academic, managed care, other). Secondary outcomes included urogynecological case list reporting, referral patterns, and residency training.ResultsA total of 473 surveys were completed; after excluding subspecialists, 210 surveys were completed by PP and 162 by individuals in other settings. 6.7% of PPs subjectively reported that they perform FPMRS + apical surgery compared with 4.3% of those in other practice settings (p = 0.33). Although 29.2% of PPs reported adequate FPMRS training in residency compared with 39.7% of those in other practice settings (p = 0.04), 53.6% of PPs reported that they refer patients with pelvic organ prolapse (POP), compared with 66.5% of those in other practice settings (p = 0.013). 38.9% of PPs report that they performed POP surgery compared with 27.8% of non-PPs (p = 0.014).ConclusionsRegardless of practice setting, surgical volumes are low and few general OB/GYN board examinees report that they perform comprehensive FPMRS ± apical support surgery. The practice environment may affect providers’ management of patients with pelvic floor disorders.

Pregnancy Outcomes after Endometrial Ablation in a Multi-institutional Cohort

Objective The objective of this study was to determine the incidence of morbidly adherent placenta in pregnancies after endometrial ablation. Study Design We performed a retrospective cohort analysis using a large, multiinstitutional deidentified clinical database, IBM EPM: Explore (IBM Corporation, Somers, NY). We identified women who underwent endometrial ablation and had a subsequent delivery between 1999 and 2016. Patients with a delivery and no prior ablation were used as controls. The association between morbidly adherent placenta, ablation, and other known risk factors for morbidly adherent placenta was analyzed using multivariable logistic regression. Results Of 162,100 reproductive‐aged women who underwent endometrial ablation, 2,770 women (1.71%) subsequently had a delivery. The rate of morbidly adherent placenta was 1 in 13.9 pregnancies after ablation compared with 1 in 838.7 pregnancies in the control group (adjusted odds ratio [aOR], 20.22, p < 0.0001). Conclusion Pregnancies that occurred after endometrial ablation were associated with increased rates of morbidly adherent placenta.

Readmission Rates after Same-Day Discharge Compared with Postoperative Day 1 Discharge after Benign Laparoscopic Hysterectomy

STUDY OBJECTIVE To determine if there is a difference in readmission rates after same-day discharge compared with postoperative day 1 discharges after laparoscopic hysterectomy. DESIGN A retrospective cohort study with 1:2 propensity score matching (Canadian Task Force classification II-2). SETTING American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Women undergoing benign laparoscopic total or supracervical hysterectomy or laparoscopic-assisted vaginal hysterectomy with or without adnexal surgery between the years 2010 to 2015. INTERVENTIONS Three thousand thirty-two low-risk women discharged on postoperative day 0 and 6064 women discharged on postoperative day 1 were included in the analysis. MEASUREMENTS AND MAIN RESULTS The overall readmission rate was 1.8%; after same-day discharge, the readmission rate was 2.2%, and after postoperative day 1 discharge the readmission rate was 1.7% (p = .10). After logistic regression analysis, smoking (adjusted odds ratio [aOR] = 2.06; 95% confidence interval [CI], 1.49-2.88), nonwhite race (aOR = 1.53; 95% CI, 1.1007-2.14), and cystoscopy (aOR = 2.05; 95% CI, 1.49-2.82) were associated with an increased risk of readmission. CONCLUSION There was no statistically significant difference in readmission rates after laparoscopic hysterectomy between women discharged on the day of surgery or postoperative day 1.