Ted M. Roth

Pyometra and recurrent prolapse after Le Fort colpocleisis

The Le Fort colpocleisis is a surgical option for advanced pelvic organ prolapse in elderly and infirm women who no longer desire coital function. It is thought that the creation of adequate lateral drainage channels will prevent the occurrence of a pyometra. The author describes the occurrence of a pyometra, despite adequate vaginal channels, necessitating hysterectomy. A 78-year-old woman presented with a 3-year history of purulent vaginal discharge that began shortly after an uncomplicated Le Fort colpocleisis. She also complained of recurrent symptomatic prolapse. Radiologic evaluation revealed a pyometra, which was confirmed at the time of laparotomy. At the time of hysterectomy, she benefitted from total colpocleisis, vaginectomy, and levator plication. The approach to recurrent prolapse after Le Fort colpocleisis is discussed. The occurrence of pyometra despite adequate drainage should affect how patients undergoing obliterative procedures for pelvic organ prolapse are counseled.

Sacral neuromodulation and cardiac pacemakers

Introduction and hypothesisPotential for cross-talk between cardiac pacemakers and sacral neuromodulation remains speculative.MethodsWe present a case series of patients with cardiac pacemakers who underwent staged Interstim (Medtronic, Minneapolis, MN) implantation and patients who had pulse generator implantation who later required cardiac pacemakers.ResultsNo cross-talk was demonstrated in either group.ConclusionsSacral neuromodulation appears to be safe in the setting of cardiac pacemakers without cardioversion/defibrillation technology.

Sacral neuromodulation and lower urinary tract dysfunction in cerebral palsy

Given the emerging role of sacral neuromodulation in treatment of neurogenic voiding dysfunction, the author describes the use of sacral neuromodulation in a patient with voiding dysfunction caused by cerebral palsy (CP). A 45-year-old patient with cerebral palsy presented with progressive complaints of urgency and overflow incontinence and was found to be in retention. She underwent sacral neuromodulation and had complete resolution of her symptoms. The literature of lower urinary tract dysfunction in CP is reviewed. It is concluded that sacral neuromodulation may be a valuable tool in treating storage and voiding disorders associated with CP.

An unexpected cause of dyspareunia and partner dyspareunia following TVT-Secur.

TVT-Secur is a new “less” invasive derivative of the tension-free vaginal tape (TVT). We report an unusual case of dyspareunia for both the patient and her husband resulting from a retained finger pad from the TVT-Secur introducer. The sling was also explanted because of malposition.

Blunt trauma leading to delayed extrusion of sacral nerve implant

Sacral neuromodulation is an effective treatment for refractory urge urinary incontinence, frequency, and urgency. Post pulse generator (IPG) adverse events requiring revision or explantation are typically pain, loss of response, and infection. We report a case of trauma-induced soft tissue injury and delayed extrusion of the IPG through the subcutaneous fat and skin. The device was explanted.

Suprapubic Approach for Repair of a Massive Vesicovaginal Fistula Utilizing a Myocutaneous Gracilis Muscle Flap

Objective The authors describe the technique of closure of a 7-cm vesicovaginal fistula involving the trigone and bladder neck with a suprapubic approach and a myocutaneous gracilis flap. Materials and Methods A patient underwent the procedure in a primary attempt to close the fistula. She required two additional procedures for correction of small cribriform fistulas, which then resulted in complete closure of the original injury. Conclusion An abdominal approach using a myocutaneous gracilis flap for the repair of a vesicovaginal fistula is a particularly useful technique for restoring a large area of tissue loss and maintaining bladder and vaginal capacity.

Subcapsular relocation for sacral neuromodulation pulse generator implant revision

Objectives:  We describe our technique and experience with subcapsular placement of the Interstim (Medtronic, Minneapolis, MN, USA) pulse generator in cases of revision for implant site pain.

Interstitial cystitis in a woman with systemic mastocytosis

Studies have reported detrusor mastocytosis in patients with interstitial cystitis. The author describes a patient with systemic mastocytosis who was confirmed to have detrusor mastocytosis and interstitial cystitis. She responded to therapy with pentosanpolysulfate. The literature on systemic mastocytosis and the role of mast cells in the pathophysiology of interstitial cystitis are reviewed.

Surgical management of vulvovaginal agglutination due to lichen planus

TO THE EDITORS: Fairchild and Haefner and Stalburg and Haefner bring to focus the disfiguring vulvovaginal effects of lichen planus and a protocol for the surgical management and postoperative care of severe vulvovaginal agglutination. Based on my experience in using this technique, I would like to point out that surgical lysis of adhesions and the sizing and placement of a firm vaginal stent may place patients who have had a hysterectomy at higher risk of vaginal dehiscence intraoperatively because of the relative avascularity of the vaginal cuff. Traditional risk factors for posthysterectomy cuff dehiscence include postmenopausal status, corticosteroid use, penetrative vaginal trauma, and a history of vaginal surgery. Thus, the patient is also at risk from the postoperative protocol, which includes several of these factors. Patients should be counseled regarding the potential for vaginal dehiscence. In the event of a vaginal dehiscence, their technique and protocol can bemodified sensibly without sacrificing anatomic success by using a soft vaginal pack (for 4 days) instead of a firmer mold, decreasing the intravaginal steroid regimen to account for the injury (200 mg every bedtime for 2 weeks and then resume the taper, as described), and starting the dilator once the pack is removed with caution to the patient to not exceed the newly established vaginal length. -