Naama Marcus-Braun

Persistent pelvic pain following transvaginal mesh surgery: a cause for mesh removal

OBJECTIVE Persistent pelvic pain after vaginal mesh surgery is an uncommon but serious complication that greatly affects womens quality of life. Our aim was to evaluate various procedures for mesh removal performed at a tertiary referral center in cases of persistent pelvic pain, and to evaluate the ensuing complications and outcomes. STUDY DESIGN A retrospective study was conducted at the University Hospital of Caen, France, including all patients treated for removal or section of vaginal mesh due to pelvic pain as a primary cause, between January 2004 and September 2009. RESULTS Ten patients met the inclusion criteria. Patients were diagnosed between 10 months and 3 years after their primary operation. Eight cases followed suburethral sling procedures and two followed mesh surgery for pelvic organ prolapse. Patients presented with obturator neuralgia (6), pudendal neuralgia (2), dyspareunia (1), and non-specific pain (1). The surgical treatment to release the mesh included: three cases of extra-peritoneal laparoscopy, four cases of complete vaginal mesh removal, one case of partial mesh removal and two cases of section of the suburethral sling. In all patients with obturator neuralgia, symptoms were resolved or improved, whereas in both cases of pudendal neuralgia the symptoms continued. There were no intra-operative complications. Post-operative Retzius hematoma was observed in one patient after laparoscopy. CONCLUSIONS Mesh removal in a tertiary center is a safe procedure, necessary in some cases of persistent pelvic pain. Obturator neuralgia seems to be easier to treat than pudendal neuralgia. Early diagnosis is the key to success in prevention of chronic disease.

Expression of estrogen receptors in the pelvic floor of pre- and post-menopausal women presenting pelvic organ prolapse

The precise role of estrogen in the pathogenesis of pelvic organ prolapse (POP) is still unclear, while the results concerning the effect of selective estrogen receptor modulators on pelvic organ prolapse are contradictory. Our aim was to test whether alteration in the expression of estrogen receptors in the pelvic floor of pre- and post-menopausal women is related to genital prolapse status. The mRNA levels of ERα and ERβ in 60 biopsy specimens were measured. Significantly higher expression of ERα and higher ERα/ERβ ratio were demonstrated in post-menopausal women compared to pre-menopausal women. Higher expression of ERα and higher ERα/ERβ ratio were detected in all studied groups with POP, thus it did not reach significance in the post-menopausal group. Pre-menopausal and post-menopausal women presenting pelvic organ prolapse had no difference in the ERα expression. Our preliminary study may indicate that pelvic organ prolapse is associated with higher expression of ERα/ERβ in the pelvic floor of both pre- and post-menopausal women; thus not reaching statistical significance in the post-menopausal women was probably due to the groups size. We believe that the inevitable changes in the estrogen receptor expression over womens different lifetimes may affect the risk of genital prolapse progression, and might contribute to the further search for appropriate selective estrogen receptor modulators as a treatment for women with pelvic organ prolapse.

Acute Urinary Retention in an Adolescent as the Presenting Symptom of Lichen Sclerosus et Atrophicus

BACKGROUND A rare case of acute urinary retention caused by labial fusion in an adolescent is described and the possible causes are discussed. CASE A 17-year-old girl, not sexually active, presented to our emergency service for acute urinary retention. Genital examination revealed labia minora fusion from the clitoris to the vaginal fourchette; urethra, and clitoris were not visualized. Sexual abuse and trauma were excluded. The labia minora were manually separated in the operating room revealing a normal vagina and urethral meatus. Skin biopsies taken from the fused labia minora revealed Lichen Sclerosus et Atrophicus. SUMMARY AND CONCLUSION Urinary retention may be seen in the face of complete adhesion of the labia minora, a rare event in postpubertal individuals. In such cases, a suspicion of underlying pathology such as asymptomatic Lichen Sclerosus should be raised and be confirmed by a biopsy.

Single port laparoscopic sacrohysteropexy in a young patient presenting with grade III uterine prolapse and rectocele

IntroductionUterine preservation in patients with uterine prolapse is a common practice in the last decade and the reconstructive pelvic operation can be done either by vaginal, abdominal or laparoscopic approach. In young patients, uterine preservation is a legitimate option and one of the proposed operations is sacro-hystero-pexy. Single Port Laparoscopy (SPL) is a relatively new technique. This is a case of a young patient presented with grade III uterine prolapse and rectocele. MethodsThe video presents the surgical technique of sacro-hystero-pexy as was described in 2001 by von Theobald, adapted specifically for the SPL technique.ConclusionsThe Single Port laparoscopy is an advanced laparoscopic technique. This video demonstrate that scaro-hystero-pexy can be done safely and efficacy with Single Port Laparoscopy without prolonging the operation time significantly.

A randomized clinical trial of knotless barbed suture vs conventional suture for closure of the uterine incision at cesarean delivery

BACKGROUND: Knotless barbed sutures are monofilament sutures with barbs cut into them. These sutures self‐anchor, maintaining tissue approximation without the need for surgical knots. OBJECTIVE: The hypothesis of this study was that knotless barbed suture could be used on the myometrium to close the hysterotomy at cesarean delivery. The objective was to compare uterine closure time, need for additional sutures, and blood loss between this and a conventional suture. STUDY DESIGN: This was a prospective, unblinded, randomized controlled trial conducted at the Ziv Medical Center, Zefat, Israel. The primary outcome was the length of time needed to close the uterine incision, which was measured from the start of the first suture on the uterus until obtaining uterine hemostasis. To minimize provider bias, women were randomized by sealed envelopes that were opened in the operating room just prior to uterine closure with either a bidirectional knotless barbed suture or conventional suture. Secondary outcomes included the number of additional hemostatic sutures needed and blood loss during incision closure. RESULTS: Patients were enrolled from August 2016 until March 2017. One hundred two women were randomized. Fifty‐one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesarean deliveries. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 minute 43 seconds (P < .001, 95% confidence interval, 67.69–138.47 seconds). Knotless barbed sutures were associated with a lower need for hemostatic sutures (median 0 vs 1, P < .001), and blood loss measured during incision closure was significantly lower (mean 221 mL vs 268 mL, P < .005). CONCLUSION: The use of a knotless barbed suture is a reasonable alternative to conventional sutures because it reduced the closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.