Jennifer J. Schmitt

Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm

OBJECTIVE To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. METHODS A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. RESULTS Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated

Outcomes of Rectovaginal Fistula Repair

800,000 in hospital costs over 5 years. CONCLUSION When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Surgical Management of the Constricted or Obliterated Vagina.

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.

Prospective Outcomes of a Pelvic Floor Rehabilitation Program Including Vaginal Electrogalvanic Stimulation for Urinary, Defecatory, and Pelvic Pain Symptoms

Management of the constricted or obliterated vagina demands an understanding and recognition of the potential etiologies leading to this presentation. A thorough and comprehensive medical and surgical review is required to arrive at an accurate diagnosis, which then will guide medical or surgical intervention. It is paramount to recognize when underlying medical conditions are contributing to these conditions and to begin medical therapy; failure to do so will often yield suboptimal results. When these conditions arise after surgical interventions, compensatory surgical techniques that correct upper and lower vaginal strictures or obliteration include incision through the stricture, vaginal advancement, Z-plasty, skin grafts, perineal flaps, and abdominal flaps and grafts. Postoperative surveillance and dilation are critical to optimize long-term success.

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

Objectives This study evaluated our experience after implementing a pelvic floor rehabilitation program including behavioral modification, biofeedback, and vaginal electrogalvanic stimulation (EGS). Methods This prospective cohort study evaluated outcomes of patients with pelvic floor dysfunction (urinary or defecatory dysfunction, pelvic pain/dyspareunia) who underwent pelvic floor rehabilitation. Patients received 4 to 7 sessions (1 every 2 weeks) including biofeedback and concluded with 30 minutes of vaginal EGS. Surveys assessed subjective changes in symptoms; success was evaluated using a 10-point visual analog scale (VAS) at the final session (10 = most successful). Paired comparisons of responses at baseline and final treatment were evaluated. Results Ninety-four patients were followed up through therapy completion. Treatment indications included urinary (89.4%), defecatory (33.0%), and pelvic pain or dyspareunia (30.9%); 44.7% of patients had a combination of indications. Among women with urinary symptoms, the percentage reporting leakage decreased from 92.9% to 79.3% (P = 0.001), leakage at least daily decreased from 69.0% to 39.5% (P < 0.001), daily urgency with leakage decreased from 42.7% to 19.5% (P = 0.001), daily urgency without leakage decreased from 41.5% to 18.3% (P < 0.001), and median VAS rating (0 = not at all, 10 = a great deal) of daily life interference decreased from 5 to 1.5 (P < 0.001). The median success ratings were 8, 8, and 7 for treatment of urinary symptoms, pelvic pain/dyspareunia, and bowel symptoms, respectively. Conclusions An aggressive pelvic rehabilitation program including biofeedback with vaginal EGS had a high rate of self-reported subjective success and satisfaction and should be considered a nonsurgical treatment option in patients with pelvic floor dysfunction.

The Impact of a Tertiary Care Vaginitis Clinic on Prescription Antimicrobials and Health Care Utilization [14M]

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.

Urogynecology digest: Presented by Jennifer Schmitt

INTRODUCTION: To evaluate the impact of a tertiary care vaginitis clinic with standardized protocols on health care utilization and prescription antifungal and antimicrobials for vaginitis-related concerns. METHODS: A retrospective analysis of electronic medical records of women with complaints of vaginitis attending a tertiary care vaginitis clinic (VC) in an integrated healthcare system. Women had vaginal microscopy, vaginal pH, an amine test, and vaginal mycology cultures at the index VC visit. Vulvovaginal candidiasis diagnoses required a positive mycology culture and bacterial vaginosis required 3 of 4 Amsels criteria. Records were analyzed to compare the number of vaginitis-related encounters (clinic and telephone), fluconazole, and metronidazole (oral and vaginal) prescriptions in the 12 months before and the 12 months after the index VC visit. RESULTS: Out of 207 women identified over an 18 month time frame, age range 16–77 years (mean 38.5 years), 71.5% had at least 1 vaginitis-related encounter in the 12 months before the index VC visit; 47.3% in the 12 months after. The mean number of visits dropped from 2.06 to 0.98 (P<.0001, paired t test). The number of women with at least one fluconazole prescription and one metronidazole prescription decreased from 53.6% to 43.0% and 39.6%–18.8% respectively (P<.0001, paired t test). CONCLUSION: Attending a tertiary care vaginitis clinic resulted in a statistically significant reduction in vaginitis-related encounters and both fluconazole and metronidazole prescriptions for 12 months. A standardized vaginitis clinic may help reduce the burden of inappropriate diagnosis and treatment of vaginitis.

Vaginal versus Robotic Hysterectomy for Commonly Cited Relative Contraindications to Vaginal Hysterectomy

This was an animal study that aimed to determine the effects of onabotulinumtoxinA (OnaBotA) on afferent bladder nerves as well as ATP and acetylcholine (ACh) release from the urothelial lining of the bladder. A mouse bladder in vitro model allowed concurrent recordings of afferent nerve activity and intravesical pressure during distension. Multiple assays measured the intraluminal and extraluminal levels of ATP, ACh, and nitric oxide (NO). Two units of OnaBotA were instilled intraluminally during bladder filling and monitored for two hours. Afferent nerve activity was analyzed to determine nerve responses to both low and high threshold filling pressures. Distension of the bladders evoked a reproducible increase in pressure and afferent nerve activity. OnaBotA decreased both the low and high pressure filling nerve activity by >60 % at 2 h in comparison to controls. Bladder compliance or release of ACh was not significantly affected after OnaBotA instillation. However, the release of intraluminal ATP decreased and the NO increased in the bladders instilled with OnaBotA. OnaBotA is a potent neurotoxin that has been shown to inhibit vesicular release of Ach at the neuromuscular junctions by preventing vesicle docking in striated muscle. However, the exact mechanism of action in smooth muscle such as the bladder remains elusive. The authors attempted to shed some light on this subject by doing an in vitro animal study investigating the effects of OnaBotA bladder instillation. They conclude that OnaBotA attenuates bladder afferent firing without affecting bladder compliance. The authors suggest that these findings could be extrapolated to human clinical medicine and that OnaBotA may have a role in treating bladder pain syndrome. The notable difference in the method of administering OnaBotA in rats may partly explain the different mode of action than that elicited in human bladders by injection. Bladder instillation of OnaBotA apparently has a rapid direct modulatory effect on afferent nerves because of its prompt crossing of the urothelial barrier, which, if reproducible in humans, could prove to be a significant advantage in patients with bladder pain syndrome. Further studies are certainly required to evaluate the safety, efficacy, and a reliable dose–response curve in humans to enable this route of administration to be considered in practice.