Steven Minaglia

Assessment of internet-based information regarding pelvic organ prolapse and urinary incontinence.

Objective This study aimed to establish descriptive data on the content, accuracy, and relevance of Internet-based information regarding pelvic organ prolapse and urinary incontinence. Methods Using the search terms, urinary incontinence, uterine prolapse, dropped uterus, cystocele, and dropped bladder, the first 20 Web sites that appeared in each of 3 highly used search engines were identified. Two experienced reviewers independently evaluated each site for specific content, relevance, and accuracy. Results A total of 220 individual sites were identified: government-, university-, and/or society-sponsored sites represented 14.1% of the identified sites. Private parties, community groups, or unknown sponsors represented 73.2% of the sites. Industry represented 12.7% of the sites. The year the site was created was displayed in 45.9% of the sites, although 66.4% of the sites contained a year of update. Overall, 45% of the sites were rated as mostly/completely relevant to the search term and 44% of the sites were rated as mostly/completely accurate. Government-, university-, and/or society-sponsored sites were significantly more likely to be rated mostly/completely relevant and mostly/completely accurate compared with all other site sponsors with P = 0.05 and P = 0.0003, respectively. Conclusions Government, university, and/or medical societies sponsor a minority of Web sites compared with other sponsors but provide more comprehensive content that is more relevant and accurate to the topics of pelvic organ prolapse and urinary incontinence.

Perineal body length among different racial groups in the first stage of labor.

Objective Anatomic differences among racial groups may contribute to observed differences in the occurrence of severe perineal lacerations at the time of vaginal delivery. The purpose of this study was to identify differences in perineal body length between racial groups. Methods Perineal body length was measured in primigravid women aged 18 to 45 years who were admitted in labor. Women were classified into 1 of 6 racial groups: White, Filipino, Japanese, Chinese, Native Hawaiian, or Micronesian. The primary outcome, perineal body length, was compared using analysis of variance. Results A total of 200 women were recruited. There were no significant differences in perineal body length (P = 0.42) and severe perineal lacerations (P = 0.82) between the different racial groups. The mean (SD) perineal body length of women who had a severe laceration was 3.9 (0.5) versus 3.9 (0.6) cm in women who did not have a severe laceration (P= 0.98). Conclusion Perineal body length does not seem to differ among the different racial groups studied and therefore an unlikely cause of racial variation in rates of severe perineal lacerations.

Pelvic organ prolapse quantification use in the literature.

Objective This study aimed to determine whether the Pelvic Organ Prolapse Quantification (POPQ) system should be simplified based on its use in the peer-reviewed literature. Methods The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and International Urogynecology Journal were used for this study. All articles relating to pelvic organ prolapse published in these journals from January 2005 to December 2010 were reviewed for their use of the POPQ system. The POPQ points described in the Materials and/or Results sections of these articles were recorded. Results Two hundred eighty-three articles using the POPQ system were identified. One hundred thirty-two (47%) articles used the POPQ system but only to determine the stage of prolapse. Specific points were not mentioned. One hundred two (36%) articles evaluated specific POPQ points (Aa, Ba, Ap, Bp, C, D). Forty-nine (17%) articles evaluated points Gh, Pb, and Tvl. Conclusions The POPQ system, based on its use in the peer-reviewed literature, may need revisions. An abbreviated version of the system may be considered, allowing for more widespread use.

Defining an at-risk population for obstetric anal sphincter laceration

OBJECTIVEnThe purpose of this study was to calculate the number of cesarean deliveries needed to prevent 1 case of obstetric anal sphincter laceration associated with operative vaginal delivery in an at-risk cohort.nnnSTUDY DESIGNnAn institutional, computerized database was used to analyze women with obstructed labor who could have been managed by either operative vaginal or cesarean delivery from September 2006 to March 2008. Women with 1 or more of the following diagnoses comprised the cohort: cephalopelvic disproportion (CPD), arrest of descent, maternal exhaustion, and fetal distress.nnnRESULTSnFifty (23.9%) out of a total of 209 women managed by operative vaginal delivery experienced an anal sphincter laceration compared to none of 254 women in the cesarean delivery group (P < .0001). The ARR therefore was 23.9% (95% confidence interval, 18.1-29.7) and the NNT was 4.2 (95% confidence interval, 3.4-5.5).nnnCONCLUSIONnFive cesarean deliveries are needed to prevent 1 anal sphincter laceration associated with operative vaginal delivery in this cohort.

Rectal mesh erosion after robotic sacrocolpopexy.

We report an unusual case of rectal mesh erosion presenting 16 months after robotic sacrocolpopexy. The patient initially underwent a robotic sacrocolpopexy, lysis of adhesions, midurethral sling, and posterior colporrhaphy for symptomatic grade 2 pelvic organ prolapse and urodynamic stress incontinence. Her postoperative recovery was uneventful. Sixteen months later, an anterior 2 × 2-cm rectal mesh erosion was noted on the colonoscopy performed when she presented with hematochezia.

Vaginal trachelectomy following laparoscopic supracervical hysterectomy and sacrocervicopexy.

Background Current evidence supports cervical preservation at the time of abdominal prolapse repair using synthetic mesh to minimize vaginal mesh extrusion. This report aims to describe management of benign cervical disease following laparoscopic sacrocervicopexy including successful trachelectomy performed vaginally. Case A 70-year-old sexually active woman presented with symptomatic pelvic organ prolapse and stress urinary incontinence. Her Papanicolaou smears over several years were unremarkable, and she had a benign endocervical polyp removed in the office 3 months before surgery. She underwent an uncomplicated robotic-assisted laparoscopic supracervical hysterectomy and sacrocervicopexy. She presented 8 months after surgery with persistent vaginal spotting after intercourse and was found to have a recurrent endocervical polyp. Ultimately, she underwent uncomplicated trachelectomy performed vaginally with resolution of her symptoms. Conclusions Retention of the cervix at the time of mesh-augmented abdominal prolapse repairs introduces a unique set of evaluation and management considerations for benign cervical disease. Trachelectomy performed vaginally was successful and uncomplicated in this case.

Urethral mesh erosion after single-incision mid-urethral sling.

Background This report aims to describe urethral mesh erosion after a single-incision synthetic midurethral sling placement and to discuss possible causes for this complication. Case A 41-year-old woman presented with recurrent stress urinary incontinence after an anchored single-incision midurethral sling placement. Cystourethroscopy and translabial pelvic ultrasonography demonstrated the size and location of the injury. Mesh removal, urethral reconstruction, and Martius transposition flap were performed. The entire mesh removed was 24% shorter than the product before insertion. Conclusion Mesh contraction may play an important role in delayed urinary tract injury especially after anchored synthetic midurethral sling placements.

Robotically-Assisted Sacrocolpopexy

The presacral space lies in the true pelvis anterior to the sacrum. Within the presacral space lies the anterior longitudinal ligament (ALL), which covers a portion of the anterior sacrum. Fixation to the ALL of the pelvic floor and reproductive tract in women has been performed for several decades as a treatment of pelvic organ prolapse (POP) (Fig. 18.1) [1]. The specific area of interest for the pelvic reconstructive surgeon lies caudal to the bifurcation of the great vessels and medial to the right ureter and sigmoid colon.

The process of efficiency.

The subject of this editorial is surgical efficiency. I have 2 objectives for writing it: The first is to convince you that surgery is a dynamic process. The second objective is to encourage more submissions to the journal that best capture this process over time. I think I hit the middle of my career, so approximately half of you will find this transformative process to be familiar. The other half may be unaware that they are already living it. Nonetheless, I hope sharing this perspective will inspire quality improvement in all of us. I did not know what a current procedural terminology code or relative value unit was when I was training. Back then, being successful at surgery meant being efficient at the procedure, minimizing complications, and helping the patient. The modern goals of patient safety and quality equate to these values, and so are part of past and present. Perhaps nothing has changed, except the fact that our government widely refers to these terms, patient safety and quality, when future resource allocation and reimbursement are discussed. I acknowledge key changes in the health care landscape that contribute to my perspective. There is now incentive to deliver highquality care. There is now disincentive to jeopardize patient safety. All of these come at a time when reimbursements are declining and the cost of care is increasing. The population is growing and people are living longer so there will be more quality and safety to provide. How must we balance these considerations? Simple; when it comes to surgery, we must be faster: we must focus on steps that improve our patient’s outcome and eliminate those that do not. We all have to deliver more care and with careful attention to available resources, including ourselves. The myriad ways to do this support an editorial series. I will start with surgical efficiency for the sake of this single editorial. The best example I can give is my experience with robotic sacrocolpopexy. The first several robotic cases clearly took more time than my laparoscopic cases, but I thought with repetition I would get better. I was eager to realize the potential benefits of this emerging technology. I was also very comfortable sitting in a chair most of the day. I quickly read as many papers and watched as many videos as I could find to accelerate the learning process. I began attaching a large grasper to the third arm on the left side of the abdomen, just lateral to the umbilicus, after watching a video furnished by an industry representative. This instrument would often hold the sigmoid and descending colon out of the way and for most of the procedure would barely be contained in the field of vision. During this process, I began to focus on the purpose of each individual instrument. Because the third arm was not doing much, I deleted it completely and substituted a 2-mm needle grasper. The benefits appeared quickly: the instrument performed the same job, the incision caused little pain, and the wound did not need to be closed. I later learned the instrument was much less expensive compared to a single use of the large grasper, an obvious bonus. After a few years of using this instrument, I deleted it as well. The assistant port placed to the right side of the umbilicus had to be used more often for retraction, but the transitions still seemed smooth. Later, I became more comfortable with the idea of bending needles and reduced the right-sided assistant trocar to 8 mm. This eliminated fascial closure of the wound, saved time, and seemed to decrease pain. I also used fewer sutures and individualized the mesh configuration over the years. Mean operative time decreased by 75 minutes during this period. I put similar modifications into my unassisted laparoscopic cases. No matter how you choose to do the procedure, consider asking the following questions: What repetitive motions can be simplified? Where do I place instruments and assistants? Do I need robotic assistance? Does the patient require a Y-shaped mesh for her particular type of repair? How many sutures are necessary? Some answers are known and some are not. The lack of data here should prompt many future studies. You often experience another surgeon’s surgical experience at a single point in time: you read a manuscript about 300 procedures or watch a video of a single procedure done in the past. It is very unlikely, if not impossible, that case number 1 was technically executed the same as case number 300. Research groups often publish manuscripts at different points in time about technically different procedures, but few write manuscripts about the transformative process that changed their technique. Standardization of surgical procedures in part creates this reality, but it is a goal I believe we should all have. Perhaps capturing the process is the key to standardization. It is clear from existing literature that formal analysis of surgical efficiency is a robust area of research. Diwadkar et al assessed vaginal surgical skills using video motion analysis of novice and experienced surgical trainees. They demonstrated that novice trainees took longer and had greater translational movement while clamping, transecting, and suturing the left uterosacral ligament. Mason et al identified time taken, path length, and number of hand movements as valid parameters in laparoscopic skills assessment in a large review. The time has come to analyze every aspect of pelvic surgery. Consider evaluating the time and economy of motion of each step, suture count, materials used and volume, needle type and modification, handedness of the surgical team members, and training level of personnel involved, for example. Consider providing supplemental digital content, such as photos and videos, when submitting a manuscript that hinges on surgical technique. Many investigators now realize it is hard to compare surgical outcomes data when EDITORIAL