Jenifer N. Byrnes

Outcomes of Rectovaginal Fistula Repair

Objectives Rectovaginal fistulae (RVF) often represent surgical challenges, and treatment must be individualized. We describe outcomes after primary surgical repair stratified by fistula etiology and surgical approach. Methods This retrospective cohort study included women who underwent surgical management of RVF at a tertiary care center between July 1, 2001 and December 31, 2013. Cases were stratified according to the following etiology: cancer (RVF-C), inflammatory bowel disease or infectious (RVF-I), and other (RVF-O). Patients with prior surgical treatment of RVF were excluded. Surgical approaches included local (seton, plug), transvaginal or endorectal, abdominal, diversion alone, or definitive (completion proctocolectomy with permanent colostomy or pelvic exenteration). Recurrence-free survival was estimated using the Kaplan-Meier method, and comparisons between subgroups were evaluated based on fitting Cox proportional hazards models. Censoring occurred at last relevant clinical follow-up. Factors contributing to recurrence-free survival were evaluated including age, body mass index, smoking status, fistula etiology, ileostomy, and surgical approach. Results During the study period, 107 women underwent surgical repair of RVF. The most common fistula etiology was RVF-I (54.2%), followed by RVF-O (23.4%), and RVF-C (22.4%). Ninety-four women underwent fistula repair by the local (29.9%), transvaginal/endorectal (25.2%), abdominal approach (19.6%), or diversion alone (13.1%), whereas 13 underwent definitive surgery (12.2%). Recurrence-free survival was significantly different depending on surgical approach (P < 0.001), but not etiology (P = 0.71). Recurrence-free survival (95% confidence interval) at 1 year after surgery was 35.2% (21.8%–56.9%) for the local approach, 55.6% (37.0%–83.3%) for the transvaginal or endorectal approach, 95% (85.9%–100%) for the abdominal approach, and 33.3% (15%–74.2%) for those with diversion only. Conclusions Recurrence rates after RVF repair are high and did not differ by fistula etiology. Abdominal repair of RVF had significantly fewer recurrences.

Hysterectomy for Benign Conditions of the Uterus: Total Vaginal Hysterectomy

As minimally invasive technology continues to be developed and refined, surgeons must be discerning in choosing the safest, cost-effective surgical approach associated with the best outcomes for each individual patient. Vaginal hysterectomy can be successfully accomplished even in challenging situations, such as previous pelvic surgery, nulliparity, uterine enlargement, or obesity. Vaginal hysterectomy should be considered the primary route for treatment of benign disease.

MRI review of female pelvic fistulizing disease: MRI of Female Pelvic Fistulizing Disease

A wide variety of fistulae occur in the female pelvis, most of which cause significant morbidity. Diagnosis, characterization, and treatment planning may be difficult using traditional imaging modalities such as fluoroscopy and computed tomography. To date, there is no comprehensive literature review of the radiologic findings associated with various types of female pelvic fistulae, and furthermore, none dedicated to magnetic resonance imaging (MRI). In this article, we seek to provide a broad overview of the MRI characteristics of female pelvic fistulizing disease in combination with epidemiologic and clinical characteristics. MRI is often considered the imaging modality of choice for evaluation of fistulae owing to its superior soft‐tissue contrast and ability to provide surgeons with the highest quality information derived from just one study, including anatomic location of fistulae and associated pelvic pathology. In other instances, MRI can be complementary to the more traditional imaging techniques. This review will describe the etiology, anatomy, MRI findings, and treatment pearls for several of the more common pelvic fistulae found in female patients, including anovaginal, rectovaginal, colovaginal, vesicovaginal, colovesical, and other complex fistulae.

72: Cost reduction techniques in the operating suite: Surgical tray optimization

Hypothesis / aims of study The American College of Obstetricians and Gynecologists supports vaginal hysterectomy as the safest and most cost effective route. While the cost-benefit ratio is favorable, there are still opportunities to optimize efficiency and contain cost. Numerous studies have highlighted the low instrument utilization within surgical trays, which results in excess processing costs and surgical case set-up time. Other risks related to excess surgical instruments include a reduction in instrument longevity from excess wearand-tear, increased risk for tray assembly errors, and unnecessary strain placed on operating suite staff from instrument tray weight. Notably, in gynecologic surgery, one study reported as few as 13% of instruments on a surgical tray were used in vaginal cases.