Michael D. Moen

Vaginal evisceration managed by transvaginal bowel resection and vaginal repair

When evisceration occurs through a large enterocele surgical repair can be performed vaginally, including bowel resection and reanastomosis, thereby avoiding the morbidity associated with laparotomy.

Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics

OBJECTIVE The objective of the study was to evaluate the use of urodynamics to determine the need for incontinence surgery at the time of abdominal sacrocolpopexy (ASC). STUDY DESIGN The records of 441 women undergoing ASC during 2005-2007 were reviewed. Group 1 consisted of 204 women (46.3%) with urodynamic stress incontinence (USI), including occult USI, who underwent incontinence surgery with ASC. Group 2 consisted of 237 women (53.7%) without USI who underwent ASC alone. Primary outcome measures were any complaint of postoperative incontinence (stress or urge) or new-onset urgency/frequency (UF). RESULTS At a mean follow-up of 46.6 weeks, the overall rate of incontinence was low and similar for both groups (13.4% in group 1 and 13.3% in group 2 [P = .967]), as was new-onset UF: 18.6% in group 1 and 11.5% in group 2 (P = .195). CONCLUSION Urodynamic evaluation appears to be useful in determining the need for incontinence surgery at the time of ASC.

Pelvic floor muscle function in women presenting with pelvic floor disorders

Introduction and hypothesisThis observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders.MethodsThree hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength.ResultsThe majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores.ConclusionsAlthough most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

Natural orifice hysterectomy.

Minimally invasive surgery (MIS) such as natural orifice surgery is perceived as a relatively recent development partly because many MIS techniques utilize new technology and devices. However, a natural orifice/MIS approach for hysterectomy (vaginal hysterectomy, VH) has existed for over a century. VH is typically thought of in the realm of the urogynecologist as a component of reconstructive pelvic surgery for pelvic organ prolapse. However, current evidence supports the use of VH in women with other benign conditions such as uterine fibroids and abnormal bleeding. Despite the evidence and availability of several MIS options for hysterectomy, the majority of hysterectomies continue to be performed via laparotomy. VH is the least invasive approach to hysterectomy, and its use should be encouraged as the preferred MIS option for women requiring uterine removal for benign conditions.

Office Management of Female Pelvic Floor Dysfunction

As the population of the United States ages, more women will present to their primary care provider or gynecologist with symptoms of pelvic floor dysfunction. Pelvic floor dysfunction includes urinary incontinence, voiding difficulties, and pelvic organ prolapse. A thorough history and physical exam is important to rule out any pelvic pathology, such as bladder cancer, which could present with overactive bladder symptoms. While a patient who wishes to proceed with surgical management for these issues may need referral to a specialist, many of these patients can undergo conservative management initially with office-based therapies. Pessaries are effective for managing prolapse and in certain cases of stress incontinence. Behavioral and medical management can improve urge incontinence and voiding dysfunction. The general gynecologist should be familiar with the basic evaluation of pelvic floor disorders, office-based treatments, and the appropriate terminology for these disorders to assist with communication when referral is indicated.

Regarding “Synthetic Graft Augmentation in Vaginal Prolapse Surgery: Long-term Objective and Subjective Outcomes”

Hypothesis / aims of study Long-term data on synthetic graft use in vaginal prolapse surgery are limited even though an increasing demand exists for more durable surgical treatment approaches for pelvic organ prolapse (POP) repair. Although currently off the market, many women received Prolift mesh augmentations and long-term post-operative outcome assessment is relevant and important. Our aim is to report long-term objective and subjective outcomes of women who have undergone transvaginal POP surgery with a synthetic graft augmentation using Prolift (Gynecare, Ethicon, Somerville, NJ, USA).

ORAL PRESENTATION 2: A Randomized Trial Comparing Methods of Vaginal Cuff Closure at Vaginal Hysterectomy and the Effect on Vaginal Length

OBJECTIVE The objective of the study was to compare the effect of horizontal versus vertical closure of the vaginal cuff during vaginal hysterectomy on vaginal length. STUDY DESIGN Forty-three women were randomized to undergo horizontal (n = 23) or vertical (n = 20) vaginal cuff closure during vaginal hysterectomy at a community hospital. The primary outcome of vaginal length before and after surgery was compared by the Student t test and the paired t test. RESULTS Preoperatively mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28 +/- 1.39 cm, respectively; P = .21). Postoperatively the groups statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P < .001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35 +/- 0.91 cm, respectively (P = .01). Within-group comparisons revealed a statistical difference between pre- versus postmean vaginal length in the horizontal group (7.76 +/- 1.23 cm versus 6.63 +/- 1.02 cm; P < .001) and no difference within the vertical group (8.28 +/- 1.39 cm versus 7.93 +/- 1.18 cm; P = .11). CONCLUSION Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length.