Zaid Chaudhry

Descending perineum syndrome: a review of the presentation, diagnosis, and management

Introduction and hypothesisDefecatory dysfunction is a relatively common and challenging problem among women and one that practicing pelvic reconstructive surgeons and gynecologists deal with frequently. A subset of defecatory dysfunction includes obstructed defecation, which can have multiple causes, one of which is descending perineum syndrome (DPS).MethodsA literature search was performed to identify the pathophysiology, diagnosis, and management of DPS.ResultsAlthough DPS has been described in the literature for many decades, it is still uncommonly diagnosed and difficult to manage. A high index of suspicion combined with physical examination consistent with excess perineal descent, patient symptom assessment, and imaging in the form of defecography are required for the diagnosis to be accurately made. Primary management options of DPS include conservative measures consisting of bowel regimens and biofeedback. Although various surgical approaches have been described in limited case series, no compelling evidence can be demonstrated at this point to support surgical intervention.ConclusionsKnowledge of DPS is essential for the practicing pelvic reconstructive surgeon to make a timely diagnosis, avoid harmful treatments, and initiate therapy early on.

Assessing Resident Surgical Volume Before and After Initiation of a Female Pelvic Medicine and Reconstructive Surgery Fellowship

OBJECTIVES The effect of fellowship programs on resident training for gynecologic surgery volume has not been clearly defined. The purpose of our study is to assess resident surgical volume for laparoscopic and vaginal hysterectomy before and after initiation of a female pelvic medicine and reconstructive surgery (FPMRS) fellowship. DESIGN A retrospective review of Accreditation Council for Graduate Medical Education Resident Case Logs of obstetrics and gynecology residents who graduated in the 3 years before and after initiation of a FPMRS fellowship was performed. Mean values of vaginal and laparoscopic hysterectomies were compared using two-tailed t-tests with statistical significance set at p < 0.05. SETTING Obstetrics and gynecology resident case logs at the Ronald Reagan University of California Los Angeles (UCLA) Medical Center were assessed. The UCLA Medical Center, located in Los Angeles, CA, is a tertiary referral center with a graduating class of 7 obstetrics and gynecology residents yearly. PARTICIPANTS Obstetrics and gynecology residents who graduated from residency 3 years before and after imitation of a FPMRS fellowship were included. In the 3 years before the start of the fellowship, 20 residents graduated, whereas 21 residents graduated after the start of the fellowship. RESULTS Residents who graduated in the 3 years after the start of the FPMRS fellowship, finished with 4.6 less vaginal hysterectomies compared with residents who graduated before the fellowship (p = 0.022). Residents who graduated in the 3 years after the start of the FPMRS fellowship finished with 3.2 more laparoscopic hysterectomies compared with residents who graduated before the fellowship although this was not significant (p = 0.25). CONCLUSIONS Resident surgical volume was significantly decreased for vaginal hysterectomy after the initiation of a FPMRS fellowship, whereas laparoscopic hysterectomy volume was not significantly changed. Longer follow-up and a national assessment are necessary to determine the broader effect of fellowship training on resident surgical experience.

Comparison of Times to Ureteral Efflux after Administration of Sodium Fluorescein and Phenazopyridine

Purpose: There is currently a national shortage of indigo carmine. In efforts to identify the most efficient aid for visualizing ureteral efflux intraoperatively we investigated the time to excretion of phenazopyridine vs a newly identified alternative, sodium fluorescein. Materials and Methods: We analyzed prospectively collected data on a cohort of women who underwent pelvic reconstructive surgery in 2015. Per provider preference patterns a number of patients were administered 200 mg phenazopyridine orally with a sip of water 1 hour prior to the start of operative time. Other patients were given 0.5 ml 10% sodium fluorescein intravenously in the operating room. In all cases time was measured between the administration of the agent and the visualization of color changes consistent with agent efflux in an indwelling catheter, which was placed at the start of the operation. Differences in excretion times between the groups were compared with the Wilcoxon rank sum test. Results: Seven women received phenazopyridine and 5 received sodium fluorescein. Mean excretion time was significantly longer in the phenazopyridine group compared to the sodium fluorescein group (81.9 vs 5.1 minutes, p = 0.0057). Median excretion time for phenazopyridine was 70 minutes (range 59 to 127) and for sodium fluorescein it was 5 minutes (range 3 to 9). Conclusions: Sodium fluorescein is excreted significantly faster in the operating room compared to phenazopyridine. Depending on the cost of these agents at an institution, in addition to the desire to decrease operative time, this may impact practice patterns and agent selection.

National Assessment of Advancing Age on Perioperative Morbidity and Length of Stay Associated With Minimally Invasive Sacrocolpopexy.

Objective The aim of the study was to assess the impact of age on 30-day perioperative complications and length of stay (LOS) for minimally invasive sacrocolpopexy (MISC) using a national database. Methods We performed an institutional review board–exempt retrospective analysis of prospectively collected data, using the National Surgical Quality Improvement Program database to analyze MISC performed at participating hospitals from 2010 to 2013. Age was stratified into the following 5 categories: younger than 60, 60 to 64, 65 to 69, 70 to 74, and 75 years or older. Complications were tabulated on the basis of available categories and were assessed using logistic multivariate regression. Length of stay was deemed abnormal if 3 days or more. Results A total of 1201 patients were identified as having undergone MISC. Mean (SD) patients age was 61.3 (11.1) years. Most patients had an American Society of Anesthesiologists (ASA) class of 2 (68.3%) or an ASA class of 3 (23.6%). Older patients had a significantly higher ASA class and lower body mass index. The most common complications were urinary tract infection (3.4%), readmission (2.7%), and return to the operating room (1.5%). Urinary tract infection (P = 0.93), readmission (P = 0.38), and return to the operating room (P = 0.17) were not significantly different between age groups. Older patients did not have greater odds of having an LOS of 3 days or more versus 1 day or 0 to 2 days. Conclusions Returns to the operating room, readmission, and urinary tract infection were the most common adverse events and did not differ between age groups. Older patients did not have greater odds of having an increased LOS. Minimally invasive sacrocolpopexy seems to be safe among appropriately selected elderly patients.

Response to comment by Petros: anatomy and cure of descending perineum syndrome

Dear Dr. Petros, We read your article regarding a novel transvaginal approach to the management of descending perineum syndrome (DPS) with great interest. Surgical treatments for this condition have not been adequately described in the literature. Certainly, some potential limitations and concerns with the approach described is the transvaginal route for the implantation of synthetic mesh in the posterior compartment—specifically relating to the risk for dyspareunia and mesh exposure. Based on your article and prior papers you have published, it appears that the amount of mesh implanted is relatively small, which should theoretically minimize these risks. The other area of variability is in the description of how the mesh is tensioned. Based on your description, it appears there is some degree of tensioning or tightening that occurs, although the original reference paper indicates that the mesh is placed in a tension-free manner. Variability in mesh tensioning will impact the reproducibility from surgeon to surgeon, which could influence postoperative complications and success rates. We look forward to additional analysis on the long-term outcomes of your patients with this challenging condition. Dr. Chaudhry. Dr. Tarnay.

Complete Excision of Sacrocolpopexy Mesh With Autologous Fascia Sacrocolpopexy

OBJECTIVE To evaluate the safety and short-term efficacy of complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy. METHODS A retrospective cohort study of patients undergoing complete sacrocolpopexy mesh excision and concomitant autologous fascia sacrocolpopexy from March 2013 to September 2016 was conducted. The primary objective was assessment of perioperative outcomes including complications within 60 days of surgery. The secondary outcome measure was surgical success defined as no need for retreatment by either surgery for apical prolapse or pessary. RESULTS Nineteen patients were identified. Median patient age was 56 years old (range 35-78). Median time from mesh placement to surgical excision was 4.5 years (0-13). Indications for mesh excision included refractory pelvic pain in 18 patients (95%), symptomatic mesh exposure in 8 patients (42%), and bilateral ureteral obstruction with ureterovaginal fistula in 1 patient (5%). Median operative time, estimated blood loss, and length of hospital stay were 228 minutes (133-362), 200 mL (50-1000), and 5 days (2-9), respectively. The rate of minor and major complications within 60 days was 36.8% and 5.3%, respectively. There were no cases of bladder or bowel injury. At a median follow-up of 9.9 months (2.4-39) no patient required secondary surgery for apical vaginal prolapse or retreatment with pessary. CONCLUSION Complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy can be accomplished safely with a low rate of major complications. These are short-term findings and longer follow-up of anatomic and functional outcomes is needed.

PD50-07 LOW SERUM TESTOSTERONE IS ASSOCIATED WITH INCREASED STRESS AND MIXED INCONTINENCE IN WOMEN

with the variables ages over 52 years (p 1⁄4 0.041), menopause (p 1⁄4 0.029) were the most susceptible to IUE permanence. ICIQ-SF variation average in group B was 9,625 points and in group C was 6,5 points. Presence of uterine prolapse implicated in increasing up to 4,75 points in average on post-operation ICIQ-SF (p1⁄40,03). VAS satisfaction average was higher in group B (8,84 1,12) than in group C(5,5 3,27). IGP-I showed better results in group B when compared to group C (p1⁄40,065). CONCLUSIONS: Weight loss through bariatric surgery completely improves SUI and its repercussions on quality of life in the vast majority of patients. Increased age and abdominal circumference raises the chance of SUI in obese women, and the age over 52 years and menopause are strongly related to the persistence of SUI after weight loss.

Authors’ reply to the comment by Shek et al. on: “Descending perineum syndrome: a review of the presentation, diagnosis, and management” by Chaudhry and Tarnay

Sir, We thank Dr. Shek and colleagues for their interest in our review on descending perineal syndrome (DPS), as well as for their comments and consideration of our article. With regard to the ‘alternate hypothesis’ proposed by Shek et al., we do concur that the pathophysiology of the condition is indeed associated with the levator hiatus and logically intimately linked to the levator ani complex. Reclassifying DPS as an epiphenomenon is also thought-provoking. Certainly there are several ‘syndromes’ in medicine whose nomenclature should probably be revisited as our understanding of the conditions evolves. However, we are not convinced that this applies to DPS. Historically, the use of the term ‘syndrome’ was first applied to the condition of descending perineum by Parks et al. in 1966 [1]. They acknowledged that the term was Bnot a wholly satisfactory title^ but continued that the term Bis descriptive, as perineal descent on straining is both the cause of the symptomatology and the most obvious physical sign.^We believe 50 years later that the term ‘syndrome’ is still apropos. This is particularly true if we are trying to be precise, given that the definition of ‘epiphenomenon’ (BA symptom appearing during the course of a disease, not of usual occurrence, and not necessarily associated with the disease^ [2]) does not appear to be applicable or additive to ‘syndrome’. DPS is not just a ‘hypermobile perineum’. As we describe in the review, DPS includes both the sign of a bulging perineum and associated symptoms of obstructed defecation. This said, women suffering with the challenges of DPS have had to date limited therapeutic options. Our practice of offering laparoscopic colpoperineopexy has offered some relief but has not been a panacea. We too await and we are hopeful of the results of the forthcoming surgical trials in women with levator avulsions.