Mikio Nihira

Surgical reconstitution of a unilaterally avulsed symptomatic puborectalis muscle using autologous fascia lata.

BACKGROUND: The puborectalis muscle is an important muscle for the maintenance of fecal continence. We present a novel surgical technique for repair of symptomatic avulsed puborectalis muscle. CASE: This woman presented with dyspareunia and fecal incontinence since the vaginal birth of her child 2 years before. The diagnosis of an avulsed right puborectalis was made by physical examination and confirmed by magnetic resonance imaging and three-dimensional ultrasonography. Fascia lata was harvested from the patient’s thigh and used to reconstitute the missing portion of the puborectalis muscle. At 12 months postoperatively, the patient was continent of stool and relieved of dyspareunia. CONCLUSION: The patient’s dyspareunia and fecal incontinence were alleviated by restoring normal anatomy.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

Three-dimensional ultrasound imaging for diagnosis of urethrovaginal fistula

We present a novel technique for visualization of a urethrovaginal fistula. A 52-year-old patient presented with persistent urinary incontinence, after having three mid-urethral sling procedures performed within the past year. The diagnosis of a urethrovaginal fistula was made by endovaginal 3-D endovaginal ultrasound and confirmed intraoperatively. We have described a novel technique that may benefit patients with urethrovaginal fistulas that are difficult to visualize.

Pain management strategies for urogynecologic surgery: a review.

Objectives The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. Methods A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. Results Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. Conclusions Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

Evaluation of Vaginal Cysts and Masses by 3-Dimensional Endovaginal and Endoanal Sonography

The purpose of this pictorial essay is to describe the utility of 3‐dimensional endovaginal and endoanal sonography in the assessment of vulvovaginal cysts and masses. It is accepted that compared with transabdominal pelvic sonography, transvaginal end‐fire sonography provides improved resolution for visualization of female reproductive organs with fewer artifacts. To visualize the structures that are located in or lateral to the vaginal canal, side‐fire 3‐dimensional endovaginal or endoanal sonography can be used. This special technique has the advantage of maintaining the spatial anatomic relationship of any abnormality in the vagina.

Transmural vaginal-to-bladder injury from an obstructed labor pattern.

BACKGROUND: A vesicovaginal fistula, among other devastating sequelae, is a complication that can arise from obstetric trauma such as prolonged obstructed labor patterns. These are rarely seen as obstetric-related complications in well-developed countries. They are thought to arise from direct ischemic injury that can occur between the fetal head and the adjacent tissues. CASE: A patient presented to the emergency room in obstructed labor. Examination revealed a crowning fetal head, no fetal heart tones, and purulent vaginal discharge. Postpartum, the patient experienced irritative voiding symptoms, vaginal stenosis, and cystoscopic evidence of injury to the bladder base. CONCLUSION: These findings may provide evidence of the transmural vaginal-to-bladder damage that can occur from obstructed labor.

Rectovaginal fistulography: a technique for the identification of recurrent elusive fistulas

Introduction and hypothesisThe purpose of this study is to review our experience with a technique for diagnosing small rectovaginal fistulas that occasionally permit passage of air or mucus.MethodsDuring an in-office visit suspicious areas of the vagina were probed with a cone-tip catheter and injected with a contrast dye to visualize the suspected fistula tract communicating to the rectum under fluoroscopic guidance. The fistulous tracts were further isolated using a flexi-tip glide wire.ResultsFive out of nine patients were found to have fistulas not diagnosed by other means. Three patients had recurrent rectovaginal fistula after a vaginal delivery, one patient was identified with a high rectovaginal fistula due to diverticular disease, and one patient had a rectovaginal fistula due to prior hemorrhoidectomy. One patient had a negative test, and the fistula that was diagnosed intraoperatively was due to underlying Crohn’s disease.ConclusionDirect fistulography is a useful technique to visualize otherwise elusive symptomatic rectovaginal fistula tracts.

Attachment of a sling rescue suture to Midurethral tape for management of potential postoperative voiding dysfunction

To investigate the utility of a polypropylene sling rescue suture (SRS) attached to mid‐portion of the mid‐urethral sling tape procedure for in office sling loosening/release using a defined algorithm.

Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach

Background: Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy. Methods: Literature searches were conducted for studies reporting the neuroanatomical sources of pain after abdominal surgery. Also, studies identified by preceding search were reviewed for relevant publications and manually retrieved. Results: Based on neuroanatomy, an optimal surgical site infiltration technique would consist of systematic, extensive, meticulous administration of local anesthetic into the peritoneum (or preperitoneum), subfascial, and subdermal tissue planes. The volume of local anesthetic would depend on the size of the incision such that 1 to 1.5 mL is injected every 1 to 2 cm of surgical incision per layer. It is best to infiltrate with a 22-gauge, 1.5-inch needle. The needle is inserted approximately 0.5 to 1 cm into the tissue plane, and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection. Conclusions: Meticulous, systematic, and extensive surgical site local anesthetic infiltration in the various tissue planes including the peritoneal, musculofascial, and subdermal tissues, where pain foci originate, provides excellent postoperative pain relief. This approach should be combined with use of other nonopioid analgesics with opioids reserved for rescue. Further well-designed studies are necessary to assess the analgesic efficacy of the proposed infiltration technique.

An ultrasound approach to the posterior compartment and anorectal dysfunction

Introduction and hypothesisPatients with anorectal dysfunction are common and can be quite challenging to diagnose. The common underlying causes for such conditions are usually anatomical in nature, which may be difficult to fully evaluate by clinical examination alone. The aim of this video was to demonstrate how multicompartmental ultrasound imaging can be utilized clinically in the evaluation of patients with anorectal dysfunction.MethodsPertinent ultrasound findings of the common anatomical causes of defecatory dysfunction were discussed in this video.ResultsDifferent ultrasound techniques were shown.ConclusionIn conclusion, multicompartmental ultrasound imaging is an easy, cost-efficient, and valuable tool in the evaluation of patients with anorectal dysfunction.