Karl Jallad

Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study.

OBJECTIVE The purpose of this study was to describe the evaluation and management of synthetic mesh-related complications after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP). STUDY DESIGN We conducted a multicenter, retrospective analysis of women who attended 4 US tertiary referral centers for evaluation of mesh-related complications after surgery for SUI and/or POP from January 2006 to December 2010. Demographic, clinical, and surgical data were abstracted from the medical record, and complications were classified according to the Expanded Accordion Severity Classification. RESULTS Three hundred forty-seven patients sought management of synthetic mesh-related complications over the study period. Index surgeries were performed for the following indications: SUI (sling only), 49.9%; POP (transvaginal mesh [TVM] or sacrocolpopexy only), 25.6%; and SUI + POP (sling + TVM or sacrocolpopexy), 24.2%. Median time to evaluation was 5.8 months (range, 0-65.2). Thirty percent of the patients had dyspareunia; 42.7% of the patients had mesh erosion; and 34.6% of the patients had pelvic pain. Seventy-seven percent of the patients had a grade 3 or 4 (severe) complication. Patients with TVM or sacrocolpopexy were more likely to have mesh erosion and vaginal symptoms compared with sling only. The median number of treatments for mesh complications was 2 (range, 1-9); 60% of the women required ≥2 interventions. Initial treatment intervention was surgical for 49% of subjects. Of those treatments that initially were managed nonsurgically, 59.3% went on to surgical intervention. CONCLUSION Most of the women who seek management of synthetic mesh complication after POP or SUI surgery have severe complications that require surgical intervention; a significant proportion require >1 surgical procedure. The pattern of complaints differs by index procedure.

Salpingo-Oophorectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery.

BACKGROUND: Vaginal hysterectomy is the preferred route of hysterectomy in benign gynecologic disease; however, a vaginal salpingo-oophorectomy can sometimes be technically challenging. Even the most skilled vaginal surgeon will occasionally have to convert to an abdominal approach to complete the procedure. TECHNIQUE: After a vaginal hysterectomy, if the surgeon is struggling to safely complete a salpingo-oophorectomy, a natural orifice transluminal endoscopic surgery (NOTES) approach could be considered. A single port is placed in the vagina and after achieving pneumoperitoneum, an endoscope is introduced to perform a survey of the pelvis and lower abdomen. The salpingo-oophorectomy can then be completed under direct visualization by using conventional laparoscopic instruments through the vaginal port. EXPERIENCE: Salpingo-oophorectomy was successfully completed in six unembalmed cadavers and in two live patients. CONCLUSION: At the time of difficult vaginal salpingo-oophorectomy, the use of a NOTES approach could circumvent the need to convert to an abdominal route. It provides clear visualization of the entire pelvic and abdominal area and is technically feasible.

Risk Factors for Microscopic Hematuria in Women

Objectives The objective of this study was to determine the risk factors that may contribute to the diagnosis of microscopic hematuria (MH) in women. Methods This multicenter case-control study reviewed cases of women presenting to Female Pelvic Medicine & Reconstructive Surgery sites with MH from 2010 to 2014. Microscopic hematuria was defined as 3 or more red blood cells per high power field in the absence of infection as indicated in the American Urologic Association guidelines. Controls were matched to cases in a 1:1 ratio and chart review of 10 risk factors was performed (urethral caruncle, pelvic organ prolapse, vaginal atrophy, personal or family history of nephrolithiasis, prior prolapse or incontinence surgery, past or current smoking, chemical exposure, family history of urologic malignancy, prior pelvic radiation, and prior alkylating chemotherapy). Odds ratios were performed to assess risk factors. Results There were 493 cases and 501 controls from 8 Female Pelvic Medicine & Reconstructive Surgery sites. Current smoking, a history of pelvic radiation, and a history of nephrolithiasis were all significant risk factors for MH (P < 0.05). Vaginal atrophy, menopausal status, and use of estrogen were not found to be risk factors for MH (P = 0.42, 0.83, and 0.80, respectively). When stratifying the quantity of MH, women with increased red blood cells per high power field were more likely to have significant findings on their imaging results. Conclusions Our findings suggest that the risk factors for MH in women are current smoking, a history of pelvic radiation, and a history of nephrolithiasis.

Breakdown of Perineal Laceration Repair After Vaginal Delivery: A Case-Control Study.

Objective The aim of the study was to estimate risk factors associated with breakdown of perineal laceration repair after vaginal delivery. Methods This is a case-control study of women who sustained a breakdown of perineal laceration repair after vaginal delivery between 2002 and 2015. Cases were patients who sustained a perineal wound breakdown after vaginal delivery and repair of a second-, third-, or fourth-degree laceration. Controls, matched 1:1, were patients who either sustained a second-, third-, or fourth-degree perineal laceration and repair without evidence of breakdown and who delivered on the same day and institution as the case. Results A total of 104,301 deliveries were assessed for breakdown of perineal laceration. One hundred forty-four met the inclusion criteria. These were matched with 144 controls. Logistic regression analysis demonstrated that smoking is associated with increased risk for breakdown of perineal laceration (adjusted odds ratio [adj. OR], 6.4; 95% confidence interval [CI], 1.2–38.5), whereas a previous vaginal delivery is protective (adj. OR, 0.14; 95% CI, 0.05-0.3). In addition, third- or fourth-degree laceration (adj. OR, 4.0; 95% CI, 1.1–15.7), presence of episiotomy at time of delivery (adj. OR, 11.1; 95% CI, 2.9–48.8), operative delivery (adj. OR, 3.4; 95% CI, 1.2–10.3), midwife performing the laceration repair (adj. OR, 4.7; 95% CI, 1.5–15.8), and use of chromic suture (adj. OR, 3.9; 95% CI, 1.6–9.8) were independent risk factors for breakdown of perineal laceration. Conclusions Smoking, nulliparity, episiotomy, operative delivery, third- or fourth-degree laceration, repair by a midwife, and use of chromic suture are independent risk factors for breakdown of perineal laceration repair after vaginal delivery.

Laparoscopic Burch Colposuspension Using a 3-Trocar System: Tips and Tricks

STUDY OBJECTIVE To describe a technique for performing laparoscopic Burch colposuspension using a 3-trocar system. DESIGN This educational video provides step-by-step instructions for performing a laparoscopic Burch colposuspension. This study was exempt from institutional review board approval. SETTING Midurethral slings are an effective surgical treatment for women with stress urinary incontinence, but not all patients are candidates for, or desire, vaginal mesh. For stress incontinence, nonmesh surgical procedures include pubovaginal fascial slings and retropubic Burch colposuspension. Colposuspension may be performed via an open or laparoscopic approach. As with other minimally invasive surgeries, laparoscopic colposuspension has decreased blood loss, pain, and length of stay with equivalent outcomes at 2 years compared with open procedures. This video describes a technique for performing laparoscopic Burch colposuspension using a 3-trocar system. INTERVENTIONS A laparoscopic Burch colposuspension is described using a 3-trocar system. Detailed step-by-step instructions are given, along with visualization of pertinent anatomy. Supplies needed for this procedure include a 0-degree, 5-mm laparoscope; two 5-mm trocars, 1 to be placed in the umbilicus and 1 in the left lower quadrant; one 5/12-mm trocar to be placed in the right lower quadrant for passing needles; a closed knot pusher; laparoscopic scissors; and 2 needle drivers. This technique assumes that the primary surgeon (located on the patients left) is right-handed and that both surgeons can suture and tie knots laparoscopically. Tips are highlighted to ensure safety and ensure successful completion of the procedure. CONCLUSION Laparoscopic Burch colposuspension offers a nonmesh-based repair for women with stress urinary incontinence using a minimally invasive approach. It is a reasonable alternative to offer patients with stress urinary incontinence who do not desire repair using vaginal mesh.

Entry into the peritoneal cavity in posthysterectomy prolapse: an educational video

Introduction and hypothesisEntry into the peritoneal cavity can be challenging in patients with posthysterectomy prolapse; however, it is important for vaginal surgeons to be able to enter the peritoneal cavity using various techniques to perform an intraperitoneal vaginal vault suspension.MethodsWe present surgical footage of various methods of accessing the peritoneal cavity in posthysterectomy prolapse using posterior, anterior and apical approaches.ResultsThis video highlights surgical techniques that can be used to enter the peritoneal cavity in posthysterectomy prolapse in a safe and reliable manner.ConclusionsVaginal surgeons should be able to safely and confidently identify and enter the peritoneal cavity using various approaches to perform an intraperitoneal vaginal vault suspension.

Vaginal hysterectomy, vaginal salpingoophorectomy and uterosacral ligament colpopexy: a view from above (in English and Spanish)

Aim of the videoThe aim of this video is to make vaginal hysterectomy (TVH), vaginal salpingoophorectomy and uterosacral ligament (USL) colpopexy approachable by showing the key procedural steps from both the vaginal and abdominal perspectives.MethodsThis production shows TVH with salpingoophorectomy and USL colpopexy that was performed on a cadaver and filmed simultaneously from the vaginal and abdominal views. The video begins with an anatomy overview from the open abdomen and proceeds with the TVH. The anterior and posterior peritoneal entries, a technique to safely and easily access the adnexa, as well as the placement of USL suspension sutures are highlighted. The proximity of the ureter and its distance from the three locations most vulnerable to injury during this procedure (the uterine artery pedicle, the infundibulopelvic ligament and the USL) are illustrated. The location of the USL suspension sutures in relation to the ischial spine, the rectum and the sacrum are demonstrated. For all of these crucial steps, a series of picture-in-picture views simultaneously showing the abdominal and vaginal perspectives are presented so that the viewer may better understand the spatial anatomy.ConclusionThis video provides the viewer with a unique anatomic perspective and helps more confidently perform TVH, vaginal salpingooophorectomy and USL colpopexy.

Surgical Anatomy of the Uterosacral Ligament Colpopexy

Objective The aim of this study was to describe the relationship of the uterosacral ligament (USL) to the ureter and rectum along a surgeons target location for suture placement under conditions simulating live surgery. Methods Dissections were performed in 11 unembalmed female cadavers. Steps were taken to identify the USL simulating USL colpopexy. Pins were placed in the midportion of the USL at the level of the IS, and at 1-cm, 2-cm, and 3-cm increments traveling proximally toward the sacrum (Fig. 1). We measured minimum distances from the USL to the ureter and rectum at each target location. Results In general, the ureters range from 1.3 to 2.0 cm lateral to the USLs along the target length. The rectum ranges from 1.9 to 2.6 cm from the right USL and remains 1.5 cm from the left USL. The mean change in distance between the ureter and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% confidence interval [CI], 0.19–0.24) on the right and 0.2 cm (95% CI, 0.18–0.27) on the left. The mean change in distance between the rectum and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% CI, 0.19–0.24) on the right and 0.0 cm (95% CI, 0–0) on the left. Conclusions For every centimeter traveled along the bilateral USLs from the IS toward the sacrum, the ureter moves 0.2 cm laterally away from the ligament, the rectum moves 0.2 cm medially away from the right USL, but maintains its position from the left USL.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Gynecology

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging field in minimally invasive surgery. NOTES can be performed via a variety of approaches, including through the stomach, esophagus, bladder, and rectum, but the majority of cases have been performed transvaginally. Potential advantages of natural orifice surgery in gynecology include the lack of abdominal incisions, less operative pain, shorter hospital stay, improved visibility, and the possibility to circumvent extensive lysis of adhesion to reach the pelvic cavity. This chapter provides a historical overview and the potential application of NOTES.

5: Various methods of entry into the peritoneal cavity in post-hysterectomy prolapse

retention or obstructive voiding symptoms, complex urinary incontinence symptoms, complicated lower urinary tract surgical history or conditions increasing the risk for poor bladder compliance or vesicoureteral reflux. An example of a normal video urodynamic study is described to demonstrate important techniques and to show the five points at which images are generally obtained. Examples of interesting study findings are discussed. Findings include bladder diverticula, detrusor overactive with leakage, poor bladder compliance, vesicoureteral reflux, stress incontinence, detrusor external sphincter dyssynergia, open bladder neck, and urethral diverticulum. CONCLUSION: Video urodynamics has several important advantages over conventional urodynamics for the evaluation of patients with lower urinary tract symptoms. It gives the clinician simultaneous functional and anatomic views of the urinary tract. While this can be of great benefit for specific patient presentations, the advantages do not come without potential risks. Financial costs and risk of radiation exposure must be weighed against the benefit. Nevertheless, in complicated patients, as illustrated here, video urodynamics may be invaluable in evaluating complex lower urinary tract dysfunction.