Jeffrey L. Cornella

Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.

OBJECTIVE: To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. METHODS: We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. RESULTS: Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3–5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. CONCLUSION: Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. LEVEL OF EVIDENCE: III

Anatomic and physiologic measurements of the internal and external anal sphincters in normal females

Objective To assess the correlation between anal sphincter magnetic resonance imaging (MRI) measurements and manometriic anorectal vectography pressures. Methods Ten healthy, nulliparous women underwent anal sphincter MRI with examination of sagittal, axial oblique, and coronal planes. Anal manometry was performed with a radial eight-channel catheter. Customary functional measurements were recorded, including anterior and posterior sphincter length, squeeze length, length of the high-pressure zone, and maximal resting and squeeze pressures. The Spearman rank correlation coefficient was used to assess correlation. Results The manometric squeeze length and the manometric length to maximum squeeze pressure were correlated negatively with the posterior sphincter length by MRI (P = .049 and .044, respectively). The manometric high-pressure zone squeeze length was correlated positively with the posterior sphincter length by MRI (P = .042). The mean ± standard deviation (SD) posterior sphincter length was 27.3 ± 6.0 mm. Anatomically, the cylindric shape of the anal sphincter is characterized by a gradual increase in muscle thickness cephalad. The external striated sphincter was much thicker posteriorly (24.7 ± 4.6 mm) than anteriorly (6.6 ± 1.7 mm) in the proximal or caudal third. The proximal internal smooth muscle sphincter was nearly equal in thickness anteriorly and posteriorly (9.0 ± 1.4 mm and 9.6 ± 1.7 mm, respectively). Although variation in the thickness of both the smooth and striated muscle was found, manometric pressures did not correlate with the muscle thickness along the sphincter. Conclusion The length of the anal sphincter correlated positively with the functional information, as determined by manometry. An anal sphincter length of 3 cm is consistent, from an anatomic and functional view, in these ten normal women.

Complications in Robotic-Assisted Gynecologic Surgery According to Case Type: A 6-Year Retrospective Cohort Study Using Clavien-Dindo Classification

STUDY OBJECTIVE To estimate the risk of postoperative complications in robotic-assisted gynecologic surgery according to case type. STUDY DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Mayo Clinic Arizona. PATIENTS All 1155 patients who underwent robotic-assisted gynecologic surgery between March 2004 and December 2009 were included. Patients were primarily white (94.3%), with a mean (SD) age of 51.5 (15.4) years, and were overweight, with body mass index (BMI) of 27.2 (6.8). INTERVENTIONS Risk of complications, overall and according to Clavien-Dindo grade, and incidence of specific complications were analyzed. Robotic-assisted gynecologic surgical procedures were categorized postoperatively according to case type as benign simple (e.g., oophorectomy, simple hysterectomy) in 552 (47.8%) patients, benign complex (e.g., excision of invasive endometriosis) in 262 (22.7%), urogynecologic in 121 (10.5%), and oncologic in 220 (19.1%). MEASUREMENTS AND MAIN RESULTS Intraoperative complications occurred in 3.2% of patients. Postoperative complications of any type occurred in 18.4% of patients. Conversion to laparotomy was necessary in 2.7%. Urologic complications were more common in urogynecologic cases (5.8%) as compared with benign simple (0.5%), benign complex (2.7%), and oncologic (3.2%). Bleeding complications were most common in oncologic cases (5%). Clavien-Dindo grade ≥ 3 complications occurred in 5.2% of patients overall, and were >3-fold likely to occur in benign complex, urogynecologic, and oncologic cases than in benign simple cases. When adjusted for age, BMI, estimated blood loss, operative time, length of stay, and previous pelvic surgery, complications were nearly twice as common for benign complex (odds ratio [OR] 1.7; 95% confidence interval [CI], 1.1-2.7), urogynecologic (OR 1.9; 95% CI, 1.0-3.4), and oncologic (OR 1.9; 95% CI, 1.1-3.1) cases as for benign simple cases, although weakly significant. Case type, BMI, estimated blood loss, and length of stay remained important factors in predicting postoperative complications. CONCLUSION The incidence of complications in robotic-assisted gynecologic surgery varies according to case type. Defining the role of patient and surgical variables such as case type in the occurrence of complications may help in identification of cases with increased risk, to improve patient counseling and surgical outcome.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

Surgical treatment of vaginal vault prolapse: a historic summary and review of outcomes.

Objectives This study aimed to review the history of surgical treatment of vaginal vault prolapse, its current treatments, and its outcomes. Methods A PubMed search was conducted using the following terms: vaginal vault prolapse, apical prolapse, surgical treatments, culdoplasty, uterosacral ligament fixation, and sacral colpopexy. Results Vaginal vault prolapse is a common condition with many surgical treatment options. Surgical principles and treatment of this condition dates back to the 19th century. Native tissue repairs such as McCall culdoplasty, uterosacral ligament fixation, and sacrospinous fixation have high overall success rates with restoring apical anatomy. Sacral colpopexy also has excellent success rates when mesh is needed to augment repairs. Conclusions There are many options for the treatment of vaginal vault prolapse. Modifications have been made to the original procedures; however, the basic principles are still applicable and include attaching the vaginal apex to level 1 support.

Office Management of Ovarian Cysts

Ovarian cysts are detected in female patients of all ages. The patients age, the size of the cyst, and the ultrasound appearance are helpful in determining which ovarian cysts necessitate observation and which necessitate surgical excision. The cancer antigen 125 level alone does not help to distinguish between benign and malignant ovarian cysts. The combination of benign findings on pelvic examination, a benign ultrasound appearance, and a cancer antigen 125 level within normal limits indicates a benign origin in practically all cases.

Needle suspension procedures for urinary stress incontinence: a review and historical perspective.

Armand J. Pereyra introduced a new approach in the treatment of female urinary stress incontinence which did not require abdominal retropubic dissection. This operation and subsequent modifications by Pereyra serve as the foundation for various needle suspension procedures. The reported cure rates for the Modified Pereyra Procedure and its variations have exceeded 85 per cent in several studies. There has been some suggestion of an increased late failure rate in the Modified Pereyra Procedure compared to abdominal retroubic urethropexy. Additional long-term studies are needed to answer this important question utilizing preoperative and postoperative urodynamic evaluation. Karram and Bhatia in their review of transvaginal needle bladder neck suspension procedures cited three studies which accomplished this in a total of 60 patients. It seems the popularity of needle suspension procedures continues to grow. Increasingly, needle suspension procedures have been used in the outpatient treatment of urinary stress incontinence. A continuing tribute to the operative contributions of Armand J. Pereyra in the treatment of urinary stress incontinence.

A Dual Benefit of Sacral Neuromodulation

Sacral neuromodulation is a therapeutic option for women with detrusor overactivity and more recently has been used in patients with fecal incontinence and slow-transit constipation. A 47-year-old woman presented with chronic constipation since childhood. She used multiple laxatives, fiber supplements, and enemas, all without success, and defecated only once per week. Extensive investigations, including barium enema, colonoscopy, defecating proctography, pelvic magnetic resonance imaging, and anorectal manometry all were normal. A transit study showed delayed small-bowel emptying. Colonic transit could not be accurately interpreted because of the marked delayed in proximal transit. An ileostomy was being considered to defunction the colon after the patient become desperate for a better quality of life. She also complained of severe urinary frequency and incomplete emptying. A cystoscopy was normal, and a temporary sacral neuromodulation device was inserted as a staged procedure to improve her urinary symptoms. From the day of device placement and thereafter, the patient defecated without difficulty and has also been free of bladder symptoms. Repeat colonic transit has shown normalization of the stomach, small bowel, and colon.

The effect of rectal distension on bladder function in patients with overactive bladder.

To investigate the effect of rectal distension on bladder sensation volumes and the number of detrusor contractions in patients with overactive bladder (OAB) symptoms.

Percutaneous bone anchor sling using synthetic mesh associated with urethral overcorrection and erosion.

Abstract: Percutaneous bone anchor bladder neck suspension has been recommended as a less morbid alternative to traditional anti-incontinence procedures. Specifically, it has reported to be associated with shorter duration of hospitalization, catheterization and urinary retention, and equivalent short-term cure rates. Recently, there have been reports of pubic osteomyelitis associated with bone anchor placement, and high incidences of recurrent incontinence. To improve the effectiveness of the procedure the placement of a suburethral synthetic collagen-impregnated mesh without tension was recommended. A specific device is included with the kit (Suture Spacer (Microvasive/Boston Scientific Corp., Natick, MA)) to prevent overcorrection of the urethrovesical junction. We present a case of urethral erosion and complete urinary retention secondary to use of a percutaneous bone anchor sling using a ProteGen mesh (Microvasive/Boston Scientific Corp., Natick, MA). Significant postoperative urethral overcorrection was noted despite intraoperative use of the Suture Spacer.