Lauren N. Siff

Native Tissue Prolapse Repairs: Comparative Effectiveness Trials

This report reviews the success rates and complications of native tissue (nonmesh) vaginal reconstruction of pelvic organ prolapse by compartment. For apical prolapse, both uterosacral ligament suspensions and sacrospinous ligament fixations are effective and provided similar outcomes in anatomy and function with few adverse events. In the anterior compartment, traditional colporrhaphy technique is no different than ultralateral suturing. In the posterior compartment, transvaginal rectocele repair is superior to transanal repair. For uterine preservation, sacrospinous hysteropexy is not inferior to vaginal hysterectomy with uterosacral ligament suspension for treatment of apical uterovaginal prolapse.

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.

Intraoperative Cystoscopic Evaluation of Ureteral Patency: A Randomized Controlled Trial.

OBJECTIVE: To compare different modalities to aid in the evaluation of intraoperative ureteral patency on cystoscopy in the postindigo carmine era. METHODS: In a randomized controlled trial, participants undergoing pelvic surgery were randomized into one of four groups: saline distention (control), 10% dextrose distention, oral phenazopyridine, or intravenous sodium fluorescein. Our primary outcome was visibility of the ureteral jets. Secondary outcomes included surgeon satisfaction; adverse reactions including allergies, urinary tract infections, urinary retention, cystoscopy times, and ureteral obstruction; and delayed diagnosis. Participants were followed for 6 weeks. A sample size of 176 participants was planned to demonstrate a 30% difference in the visibility scale. All analyses were performed in an intention-to-treat fashion. RESULTS: From February 25, 2015, through August 2015, 176 participants were enrolled; 174 completed the trial, and two did not undergo intervention. Forty-four participants were included in the phenazopyridine, dextrose, saline, and sodium fluorescein groups. Sodium fluorescein and 10% dextrose resulted in significantly improved visibility and satisfaction when compared with the control group (P<.001 and P=.004, respectively). Dextrose provided the highest satisfaction and phenazopyridine provided lowest, but visibility was not statistically different between the two groups (P=.101). Three ureteral obstructions were identified intraoperatively and none in the postoperative period. Mean total cystoscopy time varied between 4.0 and 4.8 minutes and postoperative urinary retention rate was 50% across all groups. Overall urinary tract infection rate was 24.1%, which was similar between interventions. There were no related adverse events. CONCLUSION: Compared with the control, 10% dextrose and sodium fluorescein resulted in improved visibility and provided significantly more satisfaction in the evaluation for ureteral patency with no considerable increase in operative time or morbidity. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02476448.

Surgical Pain After Transobturator and Retropubic Midurethral Sling Placement.

OBJECTIVE To compare prevalence and severity of any surgical pain between transobturator and retropubic slings; secondary aims were to compare pain at anatomic locations, pain medication use, and pain resolution between transobturator and retropubic slings and to compare pain between types of transobturator slings. METHODS This is a secondary analysis of the Trial of Mid-Urethral Slings, which compared retropubic and transobturator sling outcomes and included 597 participants from 2006 to 2008. Postoperative assessments included body maps, visual analog scales, Surgical Pain Scales, and medication inventories for 30 days, at 6 weeks, and 6, 12, and 24 months. Postoperative pain prevalence and severity were compared. Mixed models compared pain resolution and severity over time. Regression models compared pain prevalence and severity between types of transobturator slings. Eighty percent power was provided for the primary outcome pain prevalence and 95% power was provided for the primary outcome pain severity. RESULTS Postoperative prevalence of any surgical pain, pain severity, and pain medication was not different between retropubic and transobturator slings. Retropubic sling was associated with greater prevalence of suprapubic pain at 2 weeks (proportion difference 10.6%; 95% confidence interval [CI] 4.6-16.4%; P<.001). Transobturator sling was associated with greater prevalence of groin pain at 2 weeks (proportion difference 12.0%; 95% CI 7.1-16.8%; P<.001). There was no difference in pain resolution (odds ratio [OR] 1.11, 95% CI 0.88-1.40; P=.38). Between types of transobturator slings, the odds of surgical pain were similar at 2 (OR 2.39, 95% CI 0.51-11.31; P=.27) and 6 weeks (OR 0.46, 95% CI 0.02-9.20; P=.61). CONCLUSION Transobturator and retropubic slings are associated with low prevalence of any surgical pain. Transobturator sling was associated with greater prevalence of groin pain at 2 weeks, and retropubic sling was associated with greater prevalence of suprapubic pain at 2 weeks. Surgical pain resolved quickly in both groups.

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.

Surgical excision of urethral prolapse

IntroductionUrethral prolapse is a rare condition that results in the eversion of the urethral mucosa through the distal urethra. Management is divided into two categories: conservative and surgical treatment.MethodsWe present a case of urethral prolapse with severe symptoms that were minimally responsive to topical estrogen. Surgical excision was achieved with resection of the redundant urethral mucosa.ResultsThis video highlights surgical techniques that can be used for the excision of urethral prolapse.ConclusionsThe management of urethral prolapse should be individualized based on symptom severity, anatomical compromise, and surgical morbidity. Surgical management should be considered in cases of vascular compromise or failed medical management.

Nonsurgical vs. Surgical Treatment Options for Pelvic Organ Prolapse: Review of the Current Evidence

Nonsurgical management of pelvic organ prolapse is generally accepted as first-line therapy for symptomatic patients and includes expectant management, pelvic floor muscle training, or pessary use. The objective of this article is to review the available evidence comparing nonsurgical and surgical options for pelvic organ prolapse.