John B. Gebhart

Characteristics of Patients With Vaginal Rupture and Evisceration

OBJECTIVE: To characterize vaginal rupture and evisceration. METHODS: We reviewed medical records (1970–2001) for use of the diagnostic terms “vaginal rupture,” “vaginal evisceration,” and “ruptured enterocele.” RESULTS: Twelve clinical cases were identified. Patients usually presented with pain, vaginal bleeding, and abdominal pressure. In 9 of 12 women, rupture was primarily associated with postmenopausal prolapse and a history of pelvic surgery. Women with a history of abdominal hysterectomy tended to rupture through the vaginal cuff, and those with a history of vaginal hysterectomy tended to rupture through a posterior enterocele. Premenopausal rupture in 1 woman occurred postcoitally and involved the posterior fornix. Prolapse recurrence after repair was limited to 1 woman. CONCLUSIONS: Vaginal rupture and evisceration should be considered in women presenting with acute vaginal bleeding and pelvic pain. Evaluation is especially important in postmenopausal women with a history of pelvic surgery. In some cases, surveillance after pelvic surgery may prevent rupture, evisceration, and incarceration. LEVEL OF EVIDENCE: II-3

McIndoe procedure for vaginal agenesis: Long-term outcome and effect on quality of life

OBJECTIVE The purpose of this study was to evaluate quality of life, sexual function, and long-term outcome in women after undergoing the McIndoe procedure for vaginal agenesis. STUDY DESIGN This was a retrospective descriptive study of patients who were treated with the McIndoe procedure for vaginal agenesis. Participants answered a structured questionnaire to describe self-reported outcomes in quality of life, sexual function and satisfaction, and body image after the McIndoe procedure. Patient characteristics along with short- and long-term findings were abstracted from the medical record. RESULTS Eighty-six patients responded to the questionnaire. Average age (+/-SD) at surgery was 21+/-6 years (range, 12-49 years). The mean number of years (+/-SD) since surgery was 23+/-12 (range, 2-50 years). Seventy-nine percent of the respondents stated that the McIndoe procedure improved their quality of life. Ninety-one percent of the respondents were sexually active, with 75% able to achieve orgasm. Reported self-image was improved in 55% of the women. CONCLUSION The McIndoe procedure improves quality of life and sexual satisfaction and provides a functional vagina with minimal complications.

The learning curve of robotic hysterectomy

OBJECTIVE: To evaluate the learning curve of robotic hysterectomy using objective, patient-centered outcomes and analytic methods proposed in the literature. METHODS: All cases of robotic hysterectomy performed at Mayo Clinic, Rochester, Minnesota, from January 1, 2007, through December 31, 2009, were collected. Experience was analyzed in 6-month periods. Operative time, complications, and length of stay longer than 1 day were compared between periods for significant change. For learning curve analysis, standard and risk-adjusted cumulative summation charting was used for the two most experienced robotic surgeons (A and B). Outcomes of interest were intraoperative complications and intraoperative or postoperative complications within 6 weeks. Proficiency was defined as the point at which each surgeons curve crossed H0 based on complication rates of abdominal hysterectomy. Cumulative summation parameters were p0=5.7% and p1=11.4% for outcome 1 and p0=36.0% and p1=50% for outcome 2. RESULTS: In 325 cases, operative time decreased significantly from 3.5 to 2.7 hours during the 3-year period. The proportion of patients with length of stay longer than 1 day decreased significantly from 49.2% to 14.7%. Complications did not decrease significantly. The average number of procedures to cross H0 was 91 for outcome 1 and 44 for outcome 2. Observed cumulative summation curves of surgeons A and B differed from the average number of attempts calculated from p0 and p1. CONCLUSIONS: Operative time and length of stay decrease with 36 months of experience with robotic hysterectomy, whereas complications may not. Cumulative summation analysis provides an objective, individualized tool to evaluate surgical proficiency and suggests this occurs after performing approximately 91 procedures. LEVEL OF EVIDENCE: III

Noninvasive Treatment of Uterine Fibroids: Early Mayo Clinic Experience With Magnetic Resonance Imaging-Guided Focused Ultrasound

Uterine fibroids often cause symptoms of pelvic pain, pressure, and bleeding. Traditional therapies have included medical (eg, hormonal therapy) and surgical (eg, myomectomy, hysterectomy) options. Recently, uterine artery embolization was added to the treatment armamentarium. We describe an exciting new non-invasive treatment option using focused ultrasound with magnetic resonance imaging and summarize the early experience at the Mayo Clinic in Rochester, Minn, during the initial research studies of this new technology.

Xenograft use in reconstructive pelvic surgery: a review of the literature

Xenografts, bovine or porcine acellular collagen bioprostheses derived from dermis, pericardium, or small-intestine submucosa, were introduced to overcome synthetic mesh-related complications. Although there are eight commercially available xenografts, there is a paucity of empiric information to justify their use instead of the use of synthetic grafts. In addition, limited data are available about which graft characteristics are important and whether graft-reinforced repairs reduce recurrences and improve outcomes. To address these knowledge gaps, we conducted a Medline search of published reports on xenografts in animal and human trials. Histologic host response to implanted xenograft material depends primarily on chemical cross-linking and porosity, and it is limited to four responses: resorption, incorporation, encapsulation, and mixed. No clinical data unequivocally demonstrate an improved benefit to graft-reinforced repair.

Pelvic organ prolapse in defecatory disorders.

Objective: To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorders with that in control subjects. Methods: In 55 subjects with fecal incontinence, 42 subjects with obstructed defecation, and 45 healthy subjects without defecatory symptoms, a urogynecologist assessed pelvic organ prolapse by the pelvic organ prolapse quantification system, and a gastroenterologist evaluated perineal descent during simulated evacuation. A multiple logistic regression model evaluated whether obstetric-gynecological variables, including pelvic organ prolapse, could discriminate among controls, subjects with fecal incontinence, and subjects with obstructed defecation. Results: Fifty-five percent of controls, 42% of those with obstructed defecation, and 29% of those with fecal incontinence had stage II or greater prolapse by clinical examination. Eleven percent of controls, 7% of those with obstructed defecation, and 47% of subjects with fecal incontinence had a forceps delivery. Eighteen percent of controls, 31% of those with obstructed defecation, and 64% of those with fecal incontinence had a hysterectomy. Even after controlling for a higher prevalence of obstetric risk factors and hysterectomy, fecal incontinence was associated with a lower risk of stage II or greater pelvic organ prolapse (odds ratio for fecal incontinence in ≥ stage II pelvic organ prolapse relative to stage 0 pelvic organ prolapse = 0.1, 95% confidence interval 0.01–0.53). In contrast, pelvic organ prolapse severity was not associated with control versus obstructed defecation status. Seven percent of controls, 18% of subjects with obstructed defecation, and 7% of those with fecal incontinence had increased perineal descent during simulated evacuation. Excessive perineal descent was associated (P < .01) with pelvic organ prolapse. Conclusion: Despite a higher prevalence of risk factors for pelvic floor injury, pelvic organ prolapse severity was lower in those with fecal incontinence than in subjects without bowel symptoms. However, a subset of subjects with defecatory disorders, predominantly obstructed defecation, have excessive perineal descent, which is associated with pelvic organ prolapse. Level of Evidence: II-3

Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation.

A 50-year-old woman was referred for evaluation with an 8-month history of intermittent malodorous vaginal discharge initially noted 2 months after placement of a transobturator tape for stress urinary incontinence. Evaluation revealed erosion of the tape through the vaginal wall with a sinus tract associated with an ischiorectal abscess. Surgical removal of the tape with excision of the sinus tract, drain placement, and antibiotic therapy was needed for complete resolution of the symptoms. Infectious complications need to be considered when counseling women prior to synthetic sling placement. A high index of suspicion, meticulous sub- and periurethral inspection, along with aggressive surgical management are required to treat an infected draining abscess following synthetic transobturator sling placement.

Laparoscopy versus Laparotomy in the Management of Benign Unilateral Adnexal Masses

STUDY OBJECTIVE To compare operative characteristics and charges of laparoscopy and laparotomy for women with a benign unilateral adnexal mass 7 cm or less in greatest diameter. DESIGN Historical cohort study (Canadian Task Force classification II-2). SETTING Clinic department of obstetrics and gynecology. PATIENTS One hundred six women. INTERVENTION Unilateral oophorectomy or unilateral salpingo-oophorectomy performed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS When patients were compared on an intent to treat basis, no differences in greatest mass diameter (4.2 vs 4.5 cm), patient age (49.2 vs 46.4 yrs), or body mass index (26.0 vs 27.0 kg/m(2)) were found between 62 laparoscopies and 44 laparotomies. Laparoscopy was associated with longer operating times (94 vs 63 min, p <0.001), shorter hospital stay (1.6 vs 2.5 days, p <0.001), higher sterile supply charges (

Re-operation rates after permanent sacral nerve stimulation for refractory voiding dysfunction in women

1031 vs

Global endometrial ablation for menorrhagia in women with bleeding disorders

40, p <0.001), and lower hospital room charges (