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Guo X, Zhao E, Guan Z, Li W, Zhang J, Tian S, Yao Y. A retrospective study of the effects of uterine manipulators on prognosis in patients with cervical cancer. J Int Med Res 2024; 52:3000605241233966. [PMID: 38553028 PMCID: PMC10981227 DOI: 10.1177/03000605241233966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/29/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE This retrospective study investigated the effects of uterine manipulator use during minimally invasive radical hysterectomy on prognosis in patients with cervical cancer. METHODS We collected clinical data on 762 patients with stage IA2 to IIB cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy in Chinese PLA General Hospital from 2009 to 2019. Kaplan-Meier analysis and log-rank tests were used to compare the 5-year overall survival rates between patients treated with and without a uterine manipulator. RESULTS Patient demographics did not differ between the two groups. In addition, the incidence of lymphovascular space invasion, tumor size, pathologic types, the International Federation of Gynecology and Obstetrics stage, the histologic grade, and the rate of lymphatic metastases did not differ between the groups. Meanwhile, perioperative clinical indicators were similar in the groups. Furthermore, no significant differences in 5-year survival rates and survival curves were recorded between the groups among both all patients (84.5% vs. 85.6%) and early-stage patients (89.1% vs. 89.2%). CONCLUSIONS The use of uterine manipulators during minimally invasive radical hysterectomy for cervical cancer did not affect clinicopathological markers or increase the risk of death.
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Affiliation(s)
- Xinmeng Guo
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
- College of Medicine, Nankai University, 94 Weijin Road, Tianjin, China
| | - Enfeng Zhao
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Zheng Guan
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Weiping Li
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Jinning Zhang
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Shuang Tian
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Yuanqing Yao
- Department of Obstetrics and Gynecology, the First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
- College of Medicine, Nankai University, 94 Weijin Road, Tianjin, China
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Banakhevych R, Akymova K, Pariienko K, Nechaiev V. Prevention of complications of surgical treatment of stage III-IV cystocele using light polypropylene mesh. Urologia 2024; 91:212-219. [PMID: 37606212 DOI: 10.1177/03915603231193059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
OBJECTIVE The purpose of study was to report the subjective and objective results of different methods of surgical treatment of cystocele using the transvaginal Mesh-system. METHODOLOGY A prospective study was conducted from January 2017 to December 2020 comparing anterior colporrhaphy with vaginal mesh and two distinct types of vaginal wall repair sutures in the surgical treatment of cystocele. The primary endpoint was the incidence rate of vaginal wall erosion complications 12 months after surgery. Secondary endpoints were anatomic outcomes, TVM-related morbidity, and patient satisfaction measured using validated questionnaires. RESULTS In total, 102 patients with stage III-IV cystocele and the average age of 67.2 ± 3.1 years (age range of 47-79 years old) took part in the study. Of the 102 women initially enrolled, 102 (100%) were successfully followed up 12 months after primary surgery. The primary result, the objective erosion development, was radically different in the comparison groups (1.6% against 23.5%, respectively). Analysis of the improved method of operative treatment showed a prominent level of positive, uncomplicated, surgery results of 98.4% (60/61). The anatomic success rate of recovery from cystocele was 99.9% (101/102) 12 months after surgery. CONCLUSION The suggested method of restoring the anterior vaginal wall in stage III-IV isolated cystocele without signs of incomplete and complete prolapse of the uterus showed a radically positive result. The number of complications was relatively high in the comparison group, but no difference was observed in satisfaction with the anatomical results of the surgery. The percentage of the vaginal wall erosion when using a single-layer suture is 23.5%, when using a two-layer suture is 1.6.
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Affiliation(s)
- Roman Banakhevych
- Department of Obstetrics and Gynecology, Dnipro State Medical University, Dnipro, Ukraine
| | - Klavdiia Akymova
- Department of Obstetrics and Gynecology, Dnipro State Medical University, Dnipro, Ukraine
| | - Kateryna Pariienko
- Department of Obstetrics and Gynecology, Dnipro State Medical University, Dnipro, Ukraine
| | - Vsevolod Nechaiev
- Department of Obstetrics, Gynecology and Perinatology, Dnipro State Medical University, Dnipro, Ukraine
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Gutiérrez-Martínez S, Fernández-Martínez MN, Adánez-García JM, Fernández-Fernández C, Pérez-Prieto B, García-Gallego A, Gómez-Salgado J, Medina-Díaz M, Fernández-García D. Applying the Modified Ten-Group Robson Classification in a Spanish Tertiary Hospital. J Clin Med 2023; 13:252. [PMID: 38202259 PMCID: PMC10780088 DOI: 10.3390/jcm13010252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/23/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Caesarean section is necessary to save the lives of mothers and newborns at times, but it is important to perform it only when it is essential due to all the risks involved. This study aimed to examine the rate of caesarean sections performed at a tertiary hospital using the Robson classification to detect methods for the detection of and/or reduction in these caesarean section rates. METHODS A descriptive, cross-sectional study of a retrospective database was carried out. RESULTS A total of 10,317 births were assessed. The Robson classification was used to assess these interventions and verify whether the indication for performed caesarean sections was appropriate. In total, 2036 births by caesarean section were performed in the whole sample. The annual caesarean section rate varied between 18.67% and 21.18%. CONCLUSIONS Caesarean sections increased by about 20% in 2021 compared to 2020 even though the trend over the years of study was decreasing. Vaginal delivery after caesarean section is a reasonable and safe option. Caesarean section rates could be improved, mostly in Robson's Group 2. The Robson classification facilitated progress in the implementation of measures aimed at improving care and adjusting caesarean section rates.
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Affiliation(s)
- Serena Gutiérrez-Martínez
- Department of Gynecology and Obstetrics, University Hospital of León, 24071 León, Spain; (S.G.-M.); (C.F.-F.)
| | - María Nélida Fernández-Martínez
- Department of Biomedical Sciences, Institute of Biomedicine (IBIOMED), Faculty of Veterinary, University of León, 24071 León, Spain
| | - José Manuel Adánez-García
- Department of Gynecology and Obstetrics, University Hospital of Oviedo, 33011 Oviedo, Spain; (J.M.A.-G.); (M.M.-D.)
| | - Camino Fernández-Fernández
- Department of Gynecology and Obstetrics, University Hospital of León, 24071 León, Spain; (S.G.-M.); (C.F.-F.)
| | - Beatriz Pérez-Prieto
- Department of Gynecology and Obstetrics, University Hospital of León, 24071 León, Spain; (S.G.-M.); (C.F.-F.)
| | - Ana García-Gallego
- Department of Statistics and Operations Research, University of Leon, 24071 León, Spain
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21071 Huelva, Spain
- Safety and Health Postgraduate Program, Universidad Espíritu Santo, Guayaquil 092301, Ecuador
| | - María Medina-Díaz
- Department of Gynecology and Obstetrics, University Hospital of Oviedo, 33011 Oviedo, Spain; (J.M.A.-G.); (M.M.-D.)
| | - Daniel Fernández-García
- Health Research Nursing Group (GREIS), Department of Nursing and Physioterapy, University of León, 24071 León, Spain
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Sarpietro G, Foti PV, Conte C, Matarazzo MG. Role of Magnetic Resonance Imaging in Pelvic Organ Prolapse Evaluation. Medicina (Kaunas) 2023; 59:2074. [PMID: 38138177 PMCID: PMC10744532 DOI: 10.3390/medicina59122074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/27/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The primary method for assessing pelvic floor defects is through physical examination. Magnetic resonance imaging (MRI) is a radiological technique that is useful for identifying the underlying defects of pelvic floor structures that require surgery. The primary aim of this study was to find correspondence between the clinical and radiological staging of pelvic organ prolapse (POP) before and after vaginal surgery. A secondary endpoint was to investigate, through clinical and MRI findings, whether surgery influences continence mechanisms. Finally, we reported changes in the quality of life of women who underwent surgery for prolapse. Materials and Methods: Twenty-five women with prolapse stage ≥ 2 POP-Q were recruited in this prospective study. They underwent preoperative clinical examination, MRI at rest and under the Valsalva maneuver, and quality of life questionnaires. Three months after vaginal surgery, they repeated clinical and radiological evaluation. Results: Twenty women completed the study. Both clinical and MRI evaluations showed an improvement in prolapse and symptoms after surgery. There were some discrepancies between clinical and radiological staging. MRI parameters did not show differences between pre- and postoperative values at rest; under the Valsalva maneuver, instead, the measurements changed after surgery. Continence was not worsened by the widening of the vesicourethral angle. Patients reported an improvement in quality of life. Conclusions: MRI is an accurate and objective method for defining the stage of prolapse, but clinical evaluation alone is sufficient for staging prolapse before surgery and evaluating the result at follow-up. It is an accurate method for visualizing some pelvic structures that can be compromised because of pelvic organ prolapse. MRI showed that vaginal surgery does not affect continence mechanisms.
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Affiliation(s)
- Giuseppe Sarpietro
- Gynecological and Obstetrics Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, University Hospital “Policlinico-San Marco”, 95123 Catania, Italy;
| | - Carmine Conte
- Department of Woman and Child Health and Public Health, Catholic University of the Sacred Heart, 00168 Rome, Italy;
| | - Maria Grazia Matarazzo
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95124 Catania, Italy;
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Tresch C, Lallemant M, Ramanah R. Enhanced Recovery after Pelvic Organ Prolapse Surgery. J Clin Med 2023; 12:5911. [PMID: 37762852 PMCID: PMC10532386 DOI: 10.3390/jcm12185911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
The objective of this study was to review on the influence of enhanced rehabilitation in pelvic organ prolapse surgery outcomes, specifically focusing on length of hospital stay, hospital costs, pain, morbidity, and patient satisfaction. Following the PRISMA model and using PubMed as a source, eight articles pertaining to prolapse surgery and two articles concerning vaginal hysterectomies were selected, all published between 2014 and 2021. These studies revealed no significant difference in terms of operating time, intra- and post-operative complications, intra-operative blood loss and post-operative pain scores before and after the introduction of the ERAS program. Only one study noted a difference in readmission rates. There was, however, a noticeable decrease in intra-operative and post-operative intravenous intakes, opioid administration, length of stay, and overall hospital costs with the adoption of ERAS. Additionally, with ERAS, patients were able to mobilize more rapidly, and overall patient satisfaction significantly improved.
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Affiliation(s)
- Caroline Tresch
- Service de Gynécologie-Obstétrique, Université de Franche-Comté, CHU de Besançon, 25000 Besançon, France;
| | - Marine Lallemant
- Service de Gynécologie-Obstétrique, Université de Franche-Comté, CHU de Besançon, 25000 Besançon, France;
| | - Rajeev Ramanah
- Service de Gynécologie, Université de Franche-Comté, CHU de Besançon, 25000 Besançon, France;
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Sullivan ME, Michel LC, Wasser T, Clark M, Chudnoff S, Andikyan V. Changes to same day discharge after minimally invasive hysterectomy throughout COVID-19 pandemic. J Obstet Gynaecol Res 2023; 49:1418-1423. [PMID: 36808793 DOI: 10.1111/jog.15617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/05/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Minimally invasive hysterectomy is a common gynecologic procedure. Numerous studies have found that a same day discharge (SDD) is safe following this procedure. Research has found that SDDs decrease resource strain, nosocomial infections, and financial burden for both the patient and healthcare system. Due to the recent COVID-19 pandemic, the safety of hospital admissions and elective surgeries was called into question. OBJECTIVE To assess the rates of SDD among patients who underwent a minimally invasive hysterectomy before and during the COVID-19 pandemic. STUDY DESIGN A retrospective chart review was performed from September 2018 to December 2020 on 521 patients, who met inclusion criteria. Descriptive analysis, chi-square tests of association, and multivariable logistic regression were used for analysis. RESULTS There was a significant difference between rate of SDDs pre-COVID-19 (12.5%) versus during the COVID-19 period (28.6%) (p < 0.001). Surgical complexity was predictive of not being discharged the same day of surgery (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 2.2-8.8), as was surgical completion time after 4 p.m. (OR = 5.2, 95% CI = 1.1-25.2). There was no difference in readmissions (p = 0.209) and emergency department (ED) visits (p = 0.973) between SDD and overnight stay. CONCLUSION Rates of SDD for patients undergoing minimally invasive hysterectomy were significantly increased during the COVID-19 pandemic. SDDs are safe; the number of readmissions and ED visits did not increase among patients who were discharged on the same day.
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Guo X, Tian S, Wang H, Zhang J, Cheng Y, Yao Y. Outcomes associated with different surgical approaches to radical hysterectomy: A systematic review and network meta-analysis. Int J Gynaecol Obstet 2023; 160:28-37. [PMID: 35373333 DOI: 10.1002/ijgo.14209] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/04/2022] [Accepted: 03/31/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of five different approaches to cervical cancer surgery. METHODS We conducted a systematic search for comparative studies on different radical hysterectomy types for cervical cancer in PubMed, Embase, the Cochrane Library, and Web of Science databases. All included observational studies used survival analyses to compare clinical outcomes of patients undergoing different radical hysterectomy types. All studies were assessed by the Newcastle-Ottawa Scale with scores of at least seven points. We extracted the relevant data and conducted a network meta-analysis to compare clinical outcomes among five surgical approaches. RESULTS Thirty studies (n = 11 353) were included. Robotic surgery had the lowest blood loss volume and hospitalization duration; open surgery had the shortest operative time. Vaginal assisted laparoscopic surgery was associated with the highest number of resected lymph nodes and lowest rate of perioperative complications. Survival outcomes and tumor recurrence outcomes were similar among the approaches. CONCLUSION The current approaches to cervical cancer surgery have comparable efficacies.
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Affiliation(s)
- Xinmeng Guo
- College of Medicine, Nankai University, Tianjin, China
| | - Shuang Tian
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, China
| | - Hui Wang
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, China
| | - Jinning Zhang
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, China
| | - Yanfei Cheng
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, China
| | - Yuanqing Yao
- College of Medicine, Nankai University, Tianjin, China.,Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, China.,The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Rajan S, Sagili H, Durairaj J, Gupta A. Vaginal mesh erosion - a challenging entity. Trop Doct 2023; 53:176-178. [PMID: 36131508 DOI: 10.1177/00494755221125625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pelvic reconstructive surgery with mesh for pelvic organ prolapse (POP) has been reported to have a superior anatomical cure rate compared with traditional repair methods. Mesh-related adverse events are increasing worldwide. We describe a case of excision of mesh erosion following vaginal hysterectomy. A 45yr old lady presented with 3 × 2 cm infected mesh erosion on the anterior vaginal wall following a vaginal hysterectomy a year earlier in a camp setting. Cystoscopy was normal. Under anesthesia, the mesh was dissected from the vagina and excised. The vaginal edges were freshened, and approximated Postoperative period was uneventful, and she was discharged home the next day. Surgical revision is indicated for large or multiple erosions. Mesh excision can be a challenging procedure with difficulty in gaining access and increased risk of surgical bleeding. A multidisciplinary approach in conjunction with a urologist will help optimise outcomes.
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Affiliation(s)
- Saroj Rajan
- 29988Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Haritha Sagili
- 29988Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Jaylakshmi Durairaj
- 29988Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Avantika Gupta
- 29988Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Interdonato ML, Scollo P, Bignardi T, Massimello F, Ferrara M, Donatiello G, Caretto M, Mannella P, Pecorino B, Meroni MG, Simoncini T. Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery: An Italian initial experience. Front Med (Lausanne) 2022; 9:1018232. [PMID: 36582280 PMCID: PMC9792506 DOI: 10.3389/fmed.2022.1018232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
Background The aim of this study is to evaluate the initial feasibility, safety, and outcomes of hysterectomy performed by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) at three institutions in Italy. Materials and methods All women who underwent vNOTES hysterectomy ± salpingo-oophorectomy for benign indications at three tertiary referral medical centers between July 2019 and April 2021 were included in a retrospective analysis. All vNOTESs were performed with the use of Alexis® and Vpath Gel paths® (Applied Medical). Perioperative data were extracted from patient records. Patient satisfaction and dyspareunia were prospectively inquired about at 60 days and 6 months. Results Forty-six patients underwent vNOTES in the study period. Indications for surgery included myomas ± metrorrhagia (52.2%), H-Sil/in situ cervical cancer (10.7%), adenomyosis ± metrorrhagia (8.7%), BRCA 1-2 mutations (6.5%), endometrial hyperplasia (6.5%), ovarian cyst + history of breast cancer (6.5%), metrorrhagia (6.5%), and hydatidiform mole (2.2%). The mean operation time was 91.1 (±32.6) minutes. The mean hemoglobin drop was 1.2 (±0.8). The mean visual analog scale at 24 h for post-operative pain was 3.3 (±1.8). Secondary to our limited experience with the surgical technique, we favor discharge only from day 1. The mean length of hospital stay was 2 (±1.4) days. Two conversions to conventional laparoscopy were reported (4.3%), due to an obliterated pouch of Douglas and a preoperative complication. Two post-operative complications were reported (4.3%). Overall, our data on peri- and post-operative outcomes are similar to those already published for vNOTES. Conclusion Our initial experience suggests that introducing vNOTES as an alternative to conventional surgery is feasible and may offer some advantages in selected women.
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Affiliation(s)
| | - Paolo Scollo
- Department of Obstetrics and Gynecology, Cannizzaro Hospital, Catania, Italy
| | - Tommaso Bignardi
- Department of Obstetrics and Gynecology, Niguarda Hospital, Milan, Italy
| | - Francesca Massimello
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Martina Ferrara
- Department of Obstetrics and Gynecology, Cannizzaro Hospital, Catania, Italy
| | | | - Marta Caretto
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Paolo Mannella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Basilio Pecorino
- Department of Obstetrics and Gynecology, Cannizzaro Hospital, Catania, Italy
| | | | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy,*Correspondence: Tommaso Simoncini,
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Anglim BC, Tomlinson G, Paquette J, McDermott CD. A risk calculator for postoperative urinary retention (POUR) following vaginal pelvic floor surgery: multivariable prediction modelling. BJOG 2022; 129:2203-2213. [PMID: 35596931 DOI: 10.1111/1471-0528.17225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/07/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the perioperative characteristics associated with an increased risk of postoperative urinary retention (POUR) following vaginal pelvic floor surgery. DESIGN A retrospective cohort study using multivariable prediction modelling. SETTING A tertiary referral urogynaecology unit. POPULATION Patients undergoing vaginal pelvic floor surgery from January 2015 to February 2020. METHODS Eighteen variables (24 parameters) were compared between those with and without POUR and then included as potential predictors in statistical models to predict POUR. The final model was chosen as the model with the largest concordance index (c-index) from internal cross-validation. This was then externally validated using a separate data set (n = 94) from another surgical centre. MAIN OUTCOME MEASURE Diagnosis of POUR following surgery while the patient was in hospital. RESULTS Among the 700 women undergoing surgery, 301 (43%) experienced POUR. Preoperative variables with statistically significant univariate relationships with POUR included age, menopausal status, prolapse stage and uroflowmetry parameters. Significant perioperative factors included estimated blood loss, volume of intravenous fluid administered, operative time, length of stay and specific procedures, including vaginal hysterectomy with intraperitoneal vault suspension, anterior colporrhaphy, posterior colporrhaphy and colpocleisis. The lasso logistic regression model had the best combination of internally cross-validated c-index (0.73, 95% CI 0.71-0.74) and a calibration curve that showed good alignment between observed and predicted risks. Using this data, a POUR risk calculator was developed (https://pourrisk.shinyapps.io/POUR/). CONCLUSIONS This POUR risk calculator will allow physicians to counsel patients preoperatively on their risk of developing POUR after vaginal pelvic surgery and help focus discussion around potential management options.
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Affiliation(s)
- Breffini C Anglim
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network and Mt Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Joalee Paquette
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colleen D McDermott
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Tsiapakidou S, Theodoulidis I, Grimbizis G, Mikos T. Surgical excision of vaginal cysts presenting as pelvic organ prolapse: a case series. Pan Afr Med J 2022; 42:10. [PMID: 35685389 PMCID: PMC9142777 DOI: 10.11604/pamj.2022.42.10.33537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/10/2022] [Indexed: 11/12/2022] Open
Abstract
Vaginal cysts are rare, benign, predominantly cystic lesions of the anterior vaginal wall, with a prevalence of 1 in 200 women. Large vaginal cysts can occasionally present as symptomatic genital prolapse; these cases may be challenging to diagnose due to their rare clinical appearance. In symptomatic large vaginal cysts, surgical excision via vaginal approach is the recommended management with good anatomical results and patient satisfaction. The series of three consecutive adult women were referred for bothersome bulging prolapse. They were found to have a sizeable vaginal cyst at the anterior wall, associated with other symptoms. All patients (mean age 37±8.5 years) underwent total trans-vaginal surgical excision of the lesion. They were followed up in the out-patient department at six weeks and six months with no recurrences mentioned. Vaginal cysts are usually solitary, small, and asymptomatic; however, they can increase in size, easily mimic other pathologies, and are misdiagnosed as cystocele. Therefore, complete surgical vaginal excision of the symptomatic vaginal lesion is feasible and constitutes a good management option.
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Affiliation(s)
- Sofia Tsiapakidou
- 1 Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Iakovos Theodoulidis
- 1 Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Grigoris Grimbizis
- 1 Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Themistoklis Mikos
- 1 Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
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Gold RS, Amir H, Baruch Y, Gordon D, Shimonov M, Groutz A. The Manchester operation - is it time for it to return to our surgical armamentarium in the twenty-first century? J OBSTET GYNAECOL 2022; 42:1419-1423. [PMID: 34985379 DOI: 10.1080/01443615.2021.1983785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We conducted a study to assess the efficacy and outcome results of Manchester operation for women with symptomatic elongation of uterine cervix between 2010 and 2020. Forty-five women were enrolled. Mean age was 54.2 ± 10.5 years, 57.5% were premenopausal. Mean follow up was 4.53 years. Most patients were pleased from the surgery: 29 (76.3%) very pleased and three (7.9%) quite pleased. There were four cases of late postoperative complications: hematometra, pyometra, vesicovaginal fistula and small bowel evisceration through the posterior vaginal fornix. All four cases required surgical interventions with complete recovery. Manchester operation is an effective procedure for symptomatic elongation of uterine cervix. The surgery is short, minimal blood loss and without significant intraoperative complications. However, it is not free of late postoperative complications and it is therefore important that the surgery will be carried out with a strict technique and by skilled surgeons who are capable to manage unique postoperative complications.Impact StatementWhat is already known on this subject? Elongation of the uterine cervix is a condition that has not been sufficiently studied. Up-to-date data regarding the efficacy and safety of the Manchester operation for patients with cervical elongation and normal pelvic support are scarce, as most previously published studies included mainly patients with uterine prolapse.What do the results of this study add? The present study presents the efficacy, complications and clinical outcomes of Manchester operation for women with elongation of the uterine cervix. Our results show that Manchester operation is safe, effective method for symptomatic uterine cervix elongation.What are the implications of these findings for clinical practice and/or further research? This suggests Manchester operation is an effective procedure for symptomatic uterine cervix elongation should be implemented more widely. It must be carried out with a strict technique by skilled surgeons capable to manage unique postoperative complications.
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Affiliation(s)
- Ronen S Gold
- Department of Obstetrics and Gynaecology, Urogynecology and Pelvic Floor Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Amir
- Department of Obstetrics and Gynaecology, Urogynecology and Pelvic Floor Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Baruch
- Department of Obstetrics and Gynaecology, Urogynecology and Pelvic Floor Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Gordon
- Department of Obstetrics and Gynaecology, Urogynecology and Pelvic Floor Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai Shimonov
- E. Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Holon, Israel
| | - Asnat Groutz
- Department of Obstetrics and Gynaecology, Urogynecology and Pelvic Floor Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Diedrich CM, Guler Z, Hympanova L, Vodegel E, Zündel M, Mazza E, Deprest J, Roovers JP. Evaluation of the short-term host response and biomechanics of an absorbable poly-4-hydroxybutyrate scaffold in a sheep model following vaginal implantation. BJOG 2021; 129:1039-1049. [PMID: 34865300 PMCID: PMC9303173 DOI: 10.1111/1471-0528.17040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/19/2021] [Accepted: 11/30/2021] [Indexed: 12/01/2022]
Abstract
Objective To evaluate the host‐ and biomechanical response to a fully absorbable poly‐4‐hydroxybutyrate (P4HB) scaffold in comparison with the response to polypropylene (PP) mesh. Design In vivo animal experiment. Setting KU Leuven Center for Surgical Technologies. Population Fourteen parous female Mule sheep. Methods P4HB scaffolds were surgically implanted in the posterior vaginal wall of sheep. The comparative PP mesh data were obtained from an identical study protocol performed previously. Main outcome measures Gross necropsy, host response and biomechanical evaluation of explants, and the in vivo P4HB scaffold degradation were evaluated at 60‐ and 180‐days post‐implantation. Data are reported as mean ± standard deviation (SD) or standard error of the mean (SEM). Results Gross necropsy revealed no implant‐related adverse events using P4HB scaffolds. The tensile stiffness of the P4HB explants increased at 180‐days (12.498 ± 2.66 N/mm SEM [p =0.019]) as compared to 60‐days (4.585 ± 1.57 N/mm) post‐implantation, while P4HB degraded gradually. P4HB scaffolds exhibited excellent tissue integration with dense connective tissue and a moderate initial host response. P4HB scaffolds induced a significantly higher M2/M1 ratio (1.70 ± 0.67 SD, score 0–4), as compared to PP mesh(0.99 ± 0.78 SD, score 0–4) at 180‐days. Conclusions P4HB scaffold facilitated a gradual load transfer to vaginal tissue over time. The fully absorbable P4HB scaffold, in comparison to PP mesh, has a favorable host response with comparable load‐bearing capacity. If these results are also observed at longer follow‐up in‐vivo, a clinical study using P4HB for vaginal POP surgery may be warranted to demonstrate efficacy. Tweetable Abstract Degradable vaginal P4HB implant might be a solution for treatment of POP. Degradable vaginal P4HB implant might be a solution for treatment of POP.
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Affiliation(s)
- Chantal M Diedrich
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Zeliha Guler
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lucie Hympanova
- Centre for Surgical Technologies, Biomedical Sciences Group, KU Leuven, Leuven, Belgium.,Third Faculty of Medicine, Institute for the Care of Mother and Child, Charles University, Prague, Czech Republic
| | - Eva Vodegel
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manuel Zündel
- Institute of Mechanical Systems, ETH Zurich, Zurich, Switzerland.,Swiss Federal Laboratories for Materials Science and Technology, EMPA, Dübendorf, Switzerland
| | - Edoardo Mazza
- Institute of Mechanical Systems, ETH Zurich, Zurich, Switzerland.,Swiss Federal Laboratories for Materials Science and Technology, EMPA, Dübendorf, Switzerland
| | - Jan Deprest
- Centre for Surgical Technologies, Biomedical Sciences Group, KU Leuven, Leuven, Belgium
| | - Jan Paul Roovers
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Schmidt PC, Fairchild PS, Fenner DE, Rooney DM. The Fundamentals of Vaginal Surgery pilot study: developing, validating, and setting proficiency scores for a vaginal surgical skills simulation system. Am J Obstet Gynecol 2021; 225:558.e1-558.e11. [PMID: 34464583 DOI: 10.1016/j.ajog.2021.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/04/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgical training in the simulation lab can develop basic skills that translate to the operating room. Standardized, basic skills programs that are supported by validated assessment measures exist for open, laparoscopic, and endoscopic surgery; however, there is yet to be a nationally recognized and widely implemented basic skills program specifically for vaginal surgery. OBJECTIVE Develop a vaginal surgical simulation system; evaluate robust validity evidence for the simulation system and its related performance measures; and establish a proficiency score that discriminates between novice and experienced vaginal surgeon performance. STUDY DESIGN In this 3-phased study, we developed the Fundamentals of Vaginal Surgery simulation system consisting of (1) the Fundamentals of Vaginal Surgery Trainer, a task trainer; (2) a validated regimen of tasks to be performed on the trainer; and (3) performance measures to determine proficiency. In Phase I, we developed the task trainer and selected surgical tasks by performing a needs assessment and hierarchical task analyses, with review and consensus from an expert panel. In Phase II, we conducted a national survey of vaginal surgeons to collect validity evidence regarding test content, response process, and internal structure relevant to the simulation system. In Phase III, we compared performance of novice (first and second year residents) and experienced (third and fourth year residents, fellows, and faculty) surgeons on the simulation system to evaluate relevant relationships to other variables and consequences. Performance measures were analyzed to set a proficiency score that would discriminate between novice and expert (faculty) vaginal surgical performance. RESULTS A novel task trainer and 6 basic vaginal surgical skills were developed in Phase I. In Phase II, the survey responses of 48 participants (27 faculty surgeons, 6 fellows, and 14 residents) were evaluated on the dimensions of test content, response process, and internal structure. To support evidence of test content, the participants deemed the task trainer and surgical tasks representative of intended surgical field and supportive of typical surgical actions (mean scores, 3.8-4.4/5). For response process, rater-data analysis revealed high rating variability regarding prototype color. This early evidence confirmed the value of a white prototype. For internal structure, there was high agreement among rater groups (obstetricians and gynecologists generalists vs Female Pelvic Medicine and Reconstructive Surgery specialists: interclass correlation coefficient range, 0.59-0.91; learners vs faculty interclass correlation coefficient range, 0.64-1.0). There were no differences in ratings across institution type, surgeon volume, expertise (P>.14). In Phase III, we analyzed performance from 23 participants (15 [65%] obstetricians and gynecologists residents, 3 [13%] fellows, and 5 [22%] Female Pelvic Medicine and Reconstructive Surgery faculty). Experienced surgeons scored significantly higher than novice surgeons (median, 467.5; interquartile range, [402.5-542.5] vs median, 261.5; interquartile range, [211.5-351.0]; P<.001). Based on these data, setting a proficiency score threshold at 400 results in 0% (0/6) novices attaining the score, with 100% (5/5) experts exceeding it. CONCLUSION We present validity evidence relevant to all 5 sources which supports the use of this novel simulation system for basic vaginal surgical skills. To complement the system, a proficiency score of 400 was established to discriminate between novices and experts.
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Affiliation(s)
- Payton C Schmidt
- Division Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Pamela S Fairchild
- Division Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Dee E Fenner
- Division Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Deborah M Rooney
- Department of Learning and Health Sciences, University of Michigan, Ann Arbor, MI
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Sappenfield EC, Tulikangas PK, Wang R. The impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery. Am J Obstet Gynecol 2021; 225:564.e1-9. [PMID: 34480873 DOI: 10.1016/j.ajog.2021.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pelvic pain is a debilitating condition that is common among women with pelvic floor disorders. Limited information is known about the impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery. OBJECTIVE This study aimed to compare the outcomes after vaginal reconstructive surgery between women with and without preoperative pelvic pain. STUDY DESIGN Baseline and postoperative data were analyzed from the "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial." The multicenter trial involved women with anterior prolapse without symptoms of stress incontinence randomized to receive either a midurethral sling or sham incisions during a vaginal reconstructive surgery. Participants completed the visual analog scale adapted for suprapubic pain and Pelvic Floor Distress Inventory at baseline, 3 months, and 12 months. Preoperative pelvic pain was defined as a response of "5" or greater on pain on the visual analog scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question, "Do you usually experience pain in the lower abdomen or genital area?" Outcomes and complication rates were compared between women with and without pelvic pain. RESULTS The "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial" participants included 112 women with pelvic pain (58 had a midurethral sling and 54 had sham incisions) and 212 women without pelvic pain (105 had a midurethral sling and 107 had sham incisions). Women who had a midurethral sling and pelvic pain were younger than women without pelvic pain (60.3±12.1 vs 65.1±8.6; P=.004). Women who had sham incisions and pelvic pain were more likely of Hispanic ethnicity than women without pelvic pain (27.8% vs 9.4%; P=.002). Patient improvement based on the Patient Global Impression of Improvement scale did not differ between arms. Women with pelvic pain had greater improvement on the visual analog scale pain scores after a surgical procedure at 3 months (-3.1±2.9 vs -0.4±1.6; P<.001) and at 12 months (-3.4±3.0 vs -0.6±1.6; P<.001) than women without pain, although their pain scores remained higher than those without preoperative pelvic pain at all time points (P<.001 for all). Similar improvements were found on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. The differences observed were not affected by whether women were in the midurethral sling or sham arm of the trial. Postoperative urinary tract infection and incomplete bladder emptying did not differ between the groups. CONCLUSION Women with preoperative pelvic pain experienced significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery and had similar subjective improvement postoperatively compared with women without preoperative pelvic pain. Reassuringly, the performance of a midurethral sling did not have an impact on the results.
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Dengler KL, Craig ER, DiCarlo-Meacham AM, Welch EK, Brooks DI, Vaccaro CM, Gruber DD. Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial. Am J Obstet Gynecol 2021; 225:556.e1-556.e10. [PMID: 34473963 DOI: 10.1016/j.ajog.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/08/2021] [Accepted: 08/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pelvic reconstructive surgery may cause significant postoperative pain, especially with posterior colporrhaphy, contributing to a longer hospital stay and increased pain medication utilization. Regional blocks are being increasingly utilized in gynecologic surgery to improve postoperative pain and decrease opioid usage, yet preoperative pudendal blocks have not been used routinely during posterior colporrhaphy. OBJECTIVE This study aimed to compare the effect of preoperative regional pudendal nerve block using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and 3. We hypothesized that there would be a reduction in vaginal pain scores for the study group vs the control group over the first 72 hours. STUDY DESIGN This was a double-blinded, randomized controlled trial that included patients undergoing a posterior colporrhaphy, either independently or in conjunction with other vaginal or abdominal reconstructive procedures. Patients were block randomized to receive 20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study) or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before the start of surgery. Double blinding was achieved by covering four 5-mL syringes containing the randomized local anesthetic. After induction of anesthesia, a pudendal nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary outcomes included total analgesic medication usage through postoperative day 3, postoperative voiding and defecatory dysfunction, and impact of vaginal pain on quality of life factors. RESULTS A total of 120 patients were enrolled (60 in each group). There were no significant differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined liposomal and bupivacaine group at all time points vs the plain bupivacaine group. Median pain scores for the study and control groups, respectively, were 0 (0-2) and 2 (0-4) for postoperative day 1 (P=.03), 2 (1-4) and 3 (2-5) for postoperative day 2 (P=.05), and 2 (1-4) and 3 (2-5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days 2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%, P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity). CONCLUSION Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine provided more effective vaginal pain control than plain bupivacaine alone for reconstructive surgery that included posterior colporrhaphy. Given the statistically significant decrease in vaginal pain in the study group, this block may be considered as a potential adjunct for multimodal pain reduction in this patient population.
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Affiliation(s)
- Katherine L Dengler
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Eric R Craig
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Angela M DiCarlo-Meacham
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Eva K Welch
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Daniel I Brooks
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, MD
| | - Christine M Vaccaro
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Daniel D Gruber
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD; Urogynecology Department, Sibley Memorial Hospital, Johns Hopkins Medicine, Washington, DC
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Vodegel EV, Kastelein AW, Jansen CHJR, Limpens J, Zwolsman SE, Roovers JPWR, Hooijmans CR, Guler Z. The effects of oestrogen on vaginal wound healing: A systematic review and meta-analysis. Neurourol Urodyn 2021; 41:115-126. [PMID: 34643282 PMCID: PMC9293291 DOI: 10.1002/nau.24819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/16/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
Aims To determine the effects of oestrogen or oestrogen deprivation on vaginal wound healing. Impaired wound healing following prolapse surgery may increase the risk of recurrent prolapse in the future. Vaginal oestrogen therapy may improve wound healing, hereby possibly improving surgical outcomes. Methods A systematic search of OVID MEDLINE, OVID Embase, and Web of Science was conducted up to January 28, 2020. We included original studies comparing wound healing‐related outcomes of oestrogen exposed subjects (female animals and women) to hypo‐oestrogenic subjects after vaginal surgery. Data on wound healing‐related outcome measures were extracted. For each individual comparison, the standardised mean difference (Hedges' g; SMD) and 95% confidence interval (CI) were calculated. Results Of the 1474 studies reviewed, 14 studies were included for review, and 11 provided data for meta‐analysis. Oestrogen improves neovascularisation (SMD: 1.13, 95% CI: 0.67–1.60), microscopic wound closure (SMD: 0.98, 95% CI: 0.66–1.29), collagen synthesis (SMD: 1.08, 95% CI: 0.42–1.74), and tissue strength (SMD: 1.26, 95% CI: 0.53–1.99) in animals. Oestrogen increases granulation (SMD: 1.67, 95% CI: 0.54–2.79) and accelerates macroscopic wound closure (SMD: 1.82, 95% CI: 1.22–2.42) in women and animals. Oestrogen decreases the inflammatory response (SMD: −0.58, 95% CI: −1.14 to −0.02) in women and animals and reduces levels of transforming growth factor (TGF)‐β1 (SMD: −1.68, 95% CI: −2.52 to −0.83) in animals. All results were statistically significant. Conclusions Oestrogen therapy has a positive effect on vaginal wound healing. Future studies should determine whether oestrogen therapy has the potential to improve surgical outcomes.
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Affiliation(s)
- Eva V Vodegel
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC-Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnoud W Kastelein
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC-Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte H J R Jansen
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC-Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacqueline Limpens
- Department of Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sandra E Zwolsman
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC-Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC-Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Carlijn R Hooijmans
- Department of Health Evidence, Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zeliha Guler
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC-Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Allary M, Agostini A, Calderon L, Miquel L, Crochet P, Netter A. Using pneumovaginoscopy to perform the removal of a vaginal fibroid. Fertil Steril 2021; 116:1664-1666. [PMID: 34535294 DOI: 10.1016/j.fertnstert.2021.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe and assess the feasibility of a novel surgical technique (pneumovaginoscopy) for performing vaginal surgery. DESIGN Video of a single surgical procedure. SETTING A university hospital. PATIENT(S) A 42-year-old woman, gravida 2 para 2, presented with chronic pelvic pain. Vaginal examination revealed a 4-cm spherical mass bulging through her posterior vaginal wall. Magnetic resonance imaging identified this mass as either a subserosal pedunculated uterine fibroid (type 7 according to the FIGO classification) or an ectopic fibroid of the posterior vaginal wall (type 8). INTERVENTION(S) The whole procedure was performed using pneumovaginoscopy. The GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) which is the device most often used to perform transvaginal natural orifice transluminal endoscopic surgical procedures, was introduced into the vagina to create a pneumovagina. Monopolar scissors were used to create an incision through the posterior vaginal wall to reach the fibroid. Myomectomy was performed using traction movements of the fibroid associated with the dissection of the capsule. The absence of a uterine pedicle at the end of the myomectomy was in favor of an ectopic fibroid of the vagina (type 8 of the FIGO classification). The vaginal defect was closed with interrupted sutures using the access points on the GelPOINT. MAIN OUTCOME MEASURE(S) The procedure was easily and efficiently performed using the pneumovaginoscopy technique and lasted less than an hour. The patient was discharged on postoperative day 1 without any postoperative complications. She was symptom-free at her 2-month postoperative visit. RESULT(S) Compared to the classical vaginal approach, pneumovaginoscopy improves visualization through targeted lighting and close-up vision. This technique is particularly interesting in cases where the vaginal opening is narrow and for lesions located in the upper half of the vagina. Because of the unusual expansion of the vagina, increased caution is required to avoid bladder or rectal injuries. CONCLUSION(S) Pneumovaginoscopy is a novel technique that can be performed for vaginal pathologies with the same device used for transvaginal natural orifice transluminal endoscopic surgery. We described this technique and assessed its feasibility.
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Affiliation(s)
- Maud Allary
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, 13005 Marseille, Aix Marseille University, France
| | - Aubert Agostini
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, 13005 Marseille, Aix Marseille University, France
| | - Lisa Calderon
- Department of Medical Imaging, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, 13005 Marseille, Aix Marseille University, France
| | - Laura Miquel
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, 13005 Marseille, Aix Marseille University, France
| | - Patrice Crochet
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, 13005 Marseille, Aix Marseille University, France
| | - Antoine Netter
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, 13005 Marseille, Aix Marseille University, France; Institut Méditerranéen de Biodiversité et d'Écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France.
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Grimstad F, McLaren H, Gray M. The gynecologic examination of the transfeminine person after penile inversion vaginoplasty. Am J Obstet Gynecol 2021; 224:266-273. [PMID: 33039391 DOI: 10.1016/j.ajog.2020.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 01/11/2023]
Abstract
As more transfeminine patients (transgender and gender-diverse persons, sex assigned male at birth, who identify on the feminine spectrum of gender) are undergoing gender-affirming penile inversion vaginoplasty, gynecologists, as providers of vaginal care for both native and neovaginas, should be prepared to welcome these patients into their practice and offer long-term pelvic healthcare. Many parts of the anatomy, clinical examination, and aftercare differ from both native vaginas and other neovaginal surgical techniques. Transgender and gender-diverse patients cite a lack of clinician knowledge as a barrier to accessing affirming and competent healthcare. Although publications are emerging regarding this procedure, most focus on intraoperative and postoperative complications. These studies are not positioned to provide long-term pelvic health guidance or robust instruction on typical examination findings. This clinical opinion aims to address that knowledge gap by describing the gynecologic examination in the transfeminine person who has undergone a penile inversion vaginoplasty. We review the anatomic changes with surgery and the neovagina's physiology. We describe the examination of the vulva, vagina, and urethra and discuss special considerations for performing pelvic examinations on patients with a penile inversion vaginoplasty neovagina. We will also address common pathologic findings and their initial management. This clinical opinion originates from the expertise of gynecologists who have cared for high volumes of transfeminine patients who have undergone penile inversion vaginoplasties at tertiary care centers performing gender-affirming genital surgery, along with existing research on postpenile inversion vaginoplasty outcomes. Gynecologists should be familiar with the anatomic changes that occur with penile inversion vaginoplasty gender-affirming surgery and how those changes affect care. Providing transgender patients with comprehensive care including this sensitive examination can and should be part of the gynecologist's scope of practice.
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Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.
| | - Hillary McLaren
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS
| | - Meredith Gray
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS
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Taşkın S, Varlı B, Yalçın İ, Ortaç F, Taşkıran Ç, Güngör M. Morcellation in gynecology: short review and suggestions from Turkish Society of Minimally Invasive Gynecologic Oncology. J Turk Ger Gynecol Assoc 2021; 22:53-57. [PMID: 33389928 PMCID: PMC7944225 DOI: 10.4274/jtgga.galenos.2020.2020.0107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Morcellation allows the removal of a large uterus and fibroids through small incisions with minimally invasive surgery. It helps to prevent the complications associated with large incisions in both hysterectomy and myomectomy operations. Currently, there is much debate regarding the use of power morcellation in laparoscopic hysterectomy and myomectomy, mainly due to the risk of peritoneal dissemination of undiagnosed uterine sarcomas. Unfortunately, there is no valid pre-operative diagnostic method that can differentiate sarcomas from myomas, and the currently available scientific literature regarding morcellation is insufficient. As the Turkish Society of Minimally Invasive Gynecological Oncology, we present our consensus opinion and suggestions for the preoperative evaluation and morcellation of fibroids, in line with the recent literature.
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Affiliation(s)
- Salih Taşkın
- Department of Gynecologic Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Bulut Varlı
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İbrahim Yalçın
- Department of Gynecologic Oncology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Fırat Ortaç
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Çağatay Taşkıran
- Department of Gynecologic Oncology, Koç University Faculty of Medicine, İstanbul, Turkey
| | - Mete Güngör
- Department of Gynecologic Oncology, Acıbadem University Faculty of Medicine, İstanbul, Turkey
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Abstract
Vaginal hysterectomy rates in the United States are decreasing, despite it being the recommended hysterectomy route for benign hysterectomy by multiple societies. Visualization issues are a known barrier to a medical student learning in the operating room, and it is likely that this also extends to resident training. In addition, vaginal surgery can be taxing on both the surgeons and assistants, with high rates of musculoskeletal work disorders reported in vaginal surgeons. The use of a camera is integral to endoscopic surgery, and table-mounted retractor systems have been used for decades in open surgery. We bring these 2 features into vaginal surgery, that is, using a table-mounted camera system and a table-mounted vaginal retractor. When used together as demonstrated in this video, these tools can improve visualization and may improve ergonomics for the entire surgical team, including learners, during vaginal surgery.
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Affiliation(s)
- Katherine L Woodburn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Georgetown University, Washington, DC.
| | - Rosanne M Kho
- Section of Medical Gynecology and Minimally Invasive Gynecologic Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Puisungnoen N, Yantapant A, Yanaranop M. Natural Orifice Transluminal Endoscopic Surgery-assisted Vaginal Hysterectomy versus Total Laparoscopic Hysterectomy: A Single-center Retrospective Study Using Propensity Score Analysis. Gynecol Minim Invasive Ther 2020; 9:227-230. [PMID: 33312867 PMCID: PMC7713652 DOI: 10.4103/gmit.gmit_130_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 07/20/2020] [Accepted: 08/12/2020] [Indexed: 11/04/2022] Open
Abstract
Objectives The aim of this study is to evaluate the safety and efficacy of natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy (NOTES-AVH) compared with total laparoscopic hysterectomy (TLH). Materials and Methods The population was a cohort of women who underwent NOTES-AVH and TLH for a nonprolapsed uterus and benign gynecological disease between October 2015 and December 2017 at Rajavithi Hospital, Thailand. Study outcomes included operative time, the requirement of blood transfusion, perioperative complications, and postoperative pain. Factors applied for propensity score matching included age, body mass index, parity, underlying disease, previous abdominal surgery, preoperative diagnosis, presence of endometriosis, and uterine weight. Mean difference (MD) and risk ratio with 95% confidence interval (CI) were calculated to represent relative measures of the comparison. Results Among the 50 pairs, there were no differences in operative time (MD 15.9 min; 95% CI - 9.3-41.1), intraoperative complications (relative risk [RR] 0.33; 95% CI 0.04-3.10) or requirement of blood transfusion (RR 1.50; 95% CI 0.26-8.60) between the NOTES-AVH and TLH groups. NOTES-AVH was associated with lower intensity of postoperative pain (MD - 1.5 at 6-h; 95% CI - 0.8-2.2 and MD - 1.0 at 24-h; 95% CI - 0.4--1.6) and shorter length of stay (MD - 0.3 day; 95% CI - 0.1-0.7 day). Conclusion NOTES-AVH was safe and feasible for an alternative approach for hysterectomy. This technique was superior to TLH in that no abdominal incision was required, and postoperative pain was less intense.
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Affiliation(s)
- Nukun Puisungnoen
- Department of Obstetrics and Gynecology, Division of Gynecological Laparoscopy, College of Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand
| | - Aranya Yantapant
- Department of Obstetrics and Gynecology, Division of Gynecological Laparoscopy, College of Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand
| | - Marut Yanaranop
- Department of Obstetrics and Gynecology, Division of Gynecological Laparoscopy, College of Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand
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Altman AD, Robert M, Armbrust R, Fawcett WJ, Nihira M, Jones CN, Tamussino K, Sehouli J, Dowdy SC, Nelson G. Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations. Am J Obstet Gynecol 2020; 223:475-485. [PMID: 32717257 DOI: 10.1016/j.ajog.2020.07.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023]
Abstract
This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.
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Affiliation(s)
- Alon D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Magali Robert
- Department of Obstetrics and Gynecology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Robert Armbrust
- Department of Gynecology with Center for Oncological Surgery, Charité University Medicine of Berlin, European Competence Center for Ovarian Cancer, Berlin, Germany
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
| | - Mikio Nihira
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of California, Riverside, Riverside, CA
| | - Chris N Jones
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
| | - Karl Tamussino
- Division of Gynecology, Medical University of Graz, Graz, Austria
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Charité University Medicine of Berlin, European Competence Center for Ovarian Cancer, Berlin, Germany
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
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Kastelein AW, Diedrich CM, de Waal L, Ince C, Roovers JPWR. The vaginal microcirculation after prolapse surgery. Neurourol Urodyn 2019; 39:331-338. [PMID: 31691336 PMCID: PMC7004127 DOI: 10.1002/nau.24203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/20/2019] [Indexed: 01/08/2023]
Abstract
Aims Oxygen plays a crucial role in wound healing after prolapse surgery. Trauma to the vaginal vasculature might limit the delivery of oxygen to the surgical wound, which may negatively affect wound healing and regeneration of connective tissue. This possibly increases the future risk of recurrence. We aimed to determine the effects of vaginal prolapse surgery on the microcirculation of the vaginal wall. Methods We evaluated the vaginal microcirculation in healthy participants without known vascular disease undergoing anterior and/or posterior colporrhaphy. We used incident dark‐field imaging for in vivo assessment before and after (1 day, 2 weeks, and 6 weeks) surgery. We studied perfusion (microvascular flow index [MFI]), angioarchitecture (morphology/layout of microvessels) and capillary density. Results Ten women were included. Interindividual differences were observed 1 day postoperatively with regard to perfusion and angioarchitecture. Microvascular flow at the surgical site was absent or significantly reduced in some participants, whereas normal microvascular flow was observed in others (MFI range 0–3). Perfusion and angioarchitecture had been restored in all participants after 6 weeks (MFI range 2–3), regardless of the extent of vascular trauma 1 day postoperatively. Conclusions The difference in the extent of vascular trauma between women undergoing seemingly identical surgical procedures suggests that some individuals are more susceptible to vascular trauma than others. Delivery of oxygen to the wound and subsequent wound healing may be compromised in these cases, which could be related to the development of anatomical recurrence. Future studies should investigate whether there is a relationship between the vaginal microvasculature and the recurrence of prolapse.
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Affiliation(s)
- Arnoud W Kastelein
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Chantal M Diedrich
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Laura de Waal
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
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Petrikovets A, Sheyn D, Sun HH, Chapman GC, Mahajan ST, Pollard RR, El-Nashar SA, Hijaz AK, Mangel J. Multimodal opioid-sparing postoperative pain regimen compared with the standard postoperative pain regimen in vaginal pelvic reconstructive surgery: a multicenter randomized controlled trial. Am J Obstet Gynecol 2019; 221:511.e1-511.e10. [PMID: 31201808 DOI: 10.1016/j.ajog.2019.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 05/21/2019] [Accepted: 06/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use. OBJECTIVE The objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery. STUDY DESIGN This was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power). RESULTS Thirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P < .001) and received fewer narcotics during the entire hospitalization (55.7 vs 91.2, P < .001). At 96 hour follow up, patients in the ice packs, Tylenol, and Toradol group used 4.9 ketorolac tablets compared with 4.6 oxycodone/acetaminophen tablets in the standard group (P = .81); however, ice packs, Tylenol, and Toradol patients required more acetaminophen than ibuprofen by patients in the standard arm (10.7 vs 6.2 tablets, P = .012). There were no differences in Quality of Recovery Questionnaire or satisfaction scores either in the morning after surgery or at 96 hour follow up. CONCLUSION The ice packs, Tylenol, and Toradol multimodal pain regimen offers improved pain control the morning after surgery and 96 hours postoperatively compared with the standard regimen with no differences in patient satisfaction and quality of recovery. Ice packs, Tylenol, and Toradol can significantly limit postoperative inpatient narcotic use and eliminate outpatient narcotic use in patients undergoing vaginal pelvic reconstructive surgery.
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Candiani M, Ferrari SM, Marotta E, Tandoi I, Ottolina J, Salvatore S. Mini-invasive transvaginal repair of isthmocele: a video case report. Fertil Steril 2019; 111:828-830. [PMID: 30853089 DOI: 10.1016/j.fertnstert.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe our technique for transvaginal treatment of isthmocele. DESIGN Surgical video article. Local Institutional Review Board approval for the video reproduction was obtained. SETTING A scientific institute. PATIENT(S) A 26-year-old patient complaining of abnormal uterine bleeding and pelvic pain was referred to our gynecological clinic for secondary infertility. At transvaginal ultrasound examination, a cesarean scar defect of 22 × 11 mm was identified, with a residual myometrial thickness over the defect of 2 mm. INTERVENTION(S) Isthmocele excision and myometrial repair was performed transvaginal, under regional anesthesia. Before surgery, a hysteroscopy was performed to identify the dehiscence of the cesarean scar on the anterior wall of the uterus and to confirm the presence of the isthmocele and its distance from the external os. Then an incision was made at the anterior cervicovaginal junction and the bladder was dissected away until the anterior peritoneal reflection was identified. Hysteroscopic guidance by transillumination was used to identify the exact position and the limits of the isthmocele. The fibrotic tissue was then removed, and the myometrial defect was closed with interrupted sutures by using 2-0 Vicryl, engulfing the myometrial fibers that would tend to slide laterally. The vaginal mucosa was then sutured with interrupted Vicryl 2-0 sutures. At the end of the procedure, a hysteroscopy was performed to visualize the correction of the defect and to prove the continuity of the cervical canal with the uterine cavity. MAIN OUTCOME MEASURES(S) Repair of isthmocele and relief of symptoms. RESULT(S) The postoperative course was uneventful, and the patient was discharged the day after surgery. At 1-month follow-up pelvic ultrasound showed complete anatomic repair of the uterine defect. The patient was asymptomatic with no more postmenstrual bleeding. She is satisfied with the treatment and is still trying for pregnancy. CONCLUSION(S) Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.
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Affiliation(s)
- Massimo Candiani
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Elena Marotta
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Iacopo Tandoi
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Jessica Ottolina
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Salvatore
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Karmakar D, Dwyer PL, Thomas E, Schierlitz L. Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study. BJOG 2018; 126:536-542. [PMID: 30461171 DOI: 10.1111/1471-0528.15560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy. DESIGN Longitudinal clinical follow up conducted between June 2002 and December 2017. SETTING Tertiary urogynaecology centre in Melbourne, Australia. POPULATION A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP). METHODS Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively. MAIN OUTCOME MEASURES Functional and anatomical results and surgical complications. RESULTS Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain. CONCLUSION EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain. TWEETABLE ABSTRACT Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.
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Affiliation(s)
- D Karmakar
- Department of Urogynaecology, Mercy Hospital for Women, Heidelberg, Vic., Australia
| | - P L Dwyer
- Department of Urogynaecology, Mercy Hospital for Women, Heidelberg, Vic., Australia
| | - E Thomas
- Department of Urogynaecology, Mercy Hospital for Women, Heidelberg, Vic., Australia
| | - L Schierlitz
- Department of Urogynaecology, Mercy Hospital for Women, Heidelberg, Vic., Australia
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Li C, Shu H, Dai Z. Do Pelvic Organ Prolapse Quantification Examination Ba and D Guide the Selection of Operation for Severe Pelvic Organ Prolapse? J INVEST SURG 2018; 33:438-445. [PMID: 30574821 DOI: 10.1080/08941939.2018.1533055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To determine whether the preoperative Ba and D point could help to guide the choice of surgical procedure for POP. Materials and Methods: This prospective cohort study included 250 subjects with anterior/apical defect from January 2012 to June 2015. All subjects underwent a complete preoperative evaluation and completed 12 months of follow-up. Based on the connection of preoperative Ba and D point of Pelvic Organ Prolapse Quantification (POP-Q), patients were assigned two groups: 137 patients who underwent anterior vaginal repair with mesh (AVM) and 113 patients who underwent AVM combined with sacrospinous ligament fixation (SSLF). The primary outcomes were anatomical cure and recurrence rate of both procedures. Secondary outcomes were prolapse symptom, quality of life and sexual function based upon validated questionnaires. The complications were also recorded in both groups. Results: Both groups were homogeneous preoperatively. The anatomical success rates for the anterior, apical and posterior vaginal compartments were 99.2%, 97.0% and 97.7% in the AVM group, respectively. For patients who underwent AVM-SSLF, the anatomical success rates for the anterior, apical and posterior compartments were 96.1%, 98.1% and 98.1%, respectively. The recurrence for both techniques was low. Both procedures presented a significant improvement with regard to postoperative quality of life (QOL), prolapse symptoms, and sexual function after 1-year follow-up. Conclusion: The preoperative Ba and D point correlated with surgical choice for the treatment of anterior/apical prolapse, which further decided the surgical outcomes for prolapse support.
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Affiliation(s)
- Chunbo Li
- Department of Gynaecology and Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai Shi, China
| | - Huimin Shu
- Department of Gynaecology and Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai Shi, China
| | - Zhiyuan Dai
- Department of Gynaecology and Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai Shi, China
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Cheng YW, Su TH, Wang H, Huang WC, Lau HH. Risk factors and management of vaginal mesh erosion after pelvic organ prolapse surgery. Taiwan J Obstet Gynecol 2017; 56:184-187. [PMID: 28420505 DOI: 10.1016/j.tjog.2016.02.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Mesh erosion is a serious and not uncommon complication in women undergoing vaginal mesh repair. We hypothesized that mesh erosion is associated with the patient's comorbidities, surgical procedures, and mesh material. The aims of this study were to identify the risk factors and optimal management for mesh erosion. MATERIALS AND METHODS All women who underwent vaginal mesh repair from 2004 to 2014 were retrospectively reviewed. Data on patients' characteristics, presenting symptoms, treatment and outcomes were collected from their medical records. RESULTS A total of 741 women underwent vaginal mesh repairs, of whom 47 had mesh erosion. The median follow-up period was 13 months (range 3-84 months). Another nine patients with mesh erosion were referred form other hospitals. Multivariate analysis revealed that concomitant hysterectomy (odds ratio 27.02, 95% confidence interval 12.35-58.82; p < 0.01) and hypertension (odds ratio 5.95, 95% confidence interval 2.43-14.49; p < 0.01) were independent risk factors for mesh erosion. Of these 56 women, 20 (36%) were successfully treated by conservative management, while 36 (64%) required subsequent surgical revision. Compared with surgery, conservative treatment was successful if the size of the erosion was smaller than 0.5 cm (p < 0.01). Six patients (17%) had recurrent erosions after primary revision, but all successfully healed after the second surgery. CONCLUSION Concomitant hysterectomy and hypertension were associated with mesh erosion. In the management of mesh erosion, conservative treatment can be tried as the first-line treatment for smaller erosions, while surgical repair for larger erosions. Recurrent erosions could happen and requires repairs several times.
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Affiliation(s)
- Yung-Wen Cheng
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Tsung-Hsien Su
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Taipei Medical University, Taipei, Taiwan; Mackay Medical College, Taipei, Taiwan
| | - Hsuan Wang
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Wen-Chu Huang
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Mackay Medical College, Taipei, Taiwan
| | - Hui-Hsuan Lau
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Taipei Medical University, Taipei, Taiwan; Mackay Medical College, Taipei, Taiwan.
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30
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Xu HY, Yang MY, Zhang X, Wang Q, Yi XF, Ding JX, Hua KQ. Efficacy of caesarean scar defect repair in improving postmenstrual bleeding and factors associated with poor effect. J OBSTET GYNAECOL 2017; 37:1076-1081. [PMID: 28760055 DOI: 10.1080/01443615.2017.1324833] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Caesarean scar defect (CSD) can cause postmenstrual bleeding. Defect repair is an effective technique to improve this symptom, but there are still a few patients getting little improvement. This retrospective study evaluates the efficacy of scar repair and explores the factors associated with poor effect. In total, 123 patients were involved in the final analysis. All of them complained about menstruation period >7 days due to postmenstrual bleeding. Before surgery, 87.8% of patients had a menstruation period more than 10 days and 20.3% had a period more than 15 days. After surgery, a normal menstruation period (< =7 days) was achieved in 46.3% (95%CI 37.3%-55.6%) of patients and a menstruation period lasting no more than 10 days was achieved in 74.8% (95%CI 66.2%-82.2%). Through multivariate logistic analysis, four factors were found dependently associated with poor effect (defined as menstruation period >10 days after surgery): repeated caesarean section (OR 9.75, 95%CI 2.30-41.36, 0.002) was a risk factor, while defect volume >600 mm3 (OR 0.14, 95%CI 0.03-0.56, 0.006), interval from caesarean section to symptom emerging >3 months (OR 0.25, 95%CI 0.07-0.94, 0.041) and straight or retroflexed uterus (OR 0.19, 95%CI 0.05-0.79, 0.022) were protective factors. Impact statement What is already known on this subject? Caesarean scar defect can cause postmenstrual bleeding. Defect repair can improve this symptom, but there are still a few patients getting little improvement after surgery. What do the results of this study add? Defect volume >600 mm3, interval from caesarean section to symptom emerging >3 months and straight or retroflexed uterus are protective factors of poor effect (defined as menstruation period >10 days after surgery), and repeated caesarean section is a risk factor. What are the implications of these findings for clinical practice and/or further research? These findings may help in counselling the patients and in medical decision. Further researches are needed to explore other factors associated with surgical effect and build prediction models.
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Affiliation(s)
- He-Yang Xu
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Meng-Yi Yang
- b Department of Gynecology , Shanghai First Maternity and Infant Hospital , Shanghai , P.R. China
| | - Xuyin Zhang
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Qing Wang
- c Department of Gynecology , Pudong New District Maternal and Child Health Hospital , Shanghai , P.R. China
| | - Xiao-Fang Yi
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Jing-Xin Ding
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Ke-Qin Hua
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
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Torres-de la Roche LA, Devassy R, Gopalakrishnan S, de Wilde MS, Herrmann A, Larbig A, De Wilde RL. Plastic neo-vaginal construction in Mayer-Rokitansky-Küster-Hauser syndrome: an expert opinion paper on the decision-making treatment process. GMS Interdiscip Plast Reconstr Surg DGPW 2016; 5:Doc08. [PMID: 26904393 PMCID: PMC4740437 DOI: 10.3205/iprs000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vaginal agenesis is a congenital anomaly that affects the life of one of each four thousand women around the world. There is a trend that patients request immediate surgical correction, instead of passive vaginal dilatation. Therefore a differentiated counselling should be provided. We present a comparative chart, based on published evidence, with aspect to the available techniques, which will facilitate the decision-making process in the clinical practice. From our point of view, the best results are achieved with techniques that combine the advantages of the minimal-invasive surgery with those derived of the use of peritoneum as covering tissue of the neovagina. Nevertheless there is a lack on interdisciplinary consensus about the best option to restore the physical and sexual quality of life.
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Affiliation(s)
- Luz Angela Torres-de la Roche
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Rajesh Devassy
- Dubai-London Specialty Hospital, Jumeirah, Dubai, United Arab Emirates
| | | | - Maya Sophie de Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Anja Herrmann
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Angelika Larbig
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Rudy Leon De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
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Geoffrion R, Suen MW, Koenig NA, Yong P, Brennand E, Mehra N, Larouche M, Lee T, Todd NJ. Teaching Vaginal Surgery to Junior Residents: Initial Validation of 3 Novel Procedure-Specific Low-Fidelity Models. J Surg Educ 2016; 73:157-161. [PMID: 26706397 DOI: 10.1016/j.jsurg.2015.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/03/2015] [Accepted: 09/08/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Competency-based surgical education relies on operative models to teach surgical skills within a curriculum. Low fidelity simulation has been shown to improve surgical performance. Our objectives were: to develop procedure-specific models to teach anterior repair (AR), posterior repair (PR), and vaginal hysterectomy (VH) to junior residents; to establish model reliability and validity. DESIGN Residents were randomized to control (no training) and intervention (model training) groups. They were filmed while performing a series of tasks. Experts were also filmed. Each video was scored by 2 blinded raters. SETTING Multicenter collaboration within the Western Society of Pelvic Medicine (Vancouver, Calgary, and Edmonton). Face and content validity were evaluated. A standard scoring tool was developed for performance evaluation. Interrater reliability was assessed using intraclass correlation coefficient. Cronbach α was calculated for internal consistency. Jonckheere-Terpstra test verified whether the scores increased with operator skill level. PARTICIPANTS A total of 14 junior gynecology residents, 2 urogynecology fellows, and 3 staff urogynecologists were rated by a total of 6 gynecologic surgeons who scored 42 videos each. RESULTS Experienced pelvic surgeons from 3 participating sites agreed the models captured essential elements of real surgical skills (face validity) and of the true procedures (content validity). Intraclass correlation coefficient was adequate (AR = 0.86, PR = 0.90, and VH = 0.87). Cronbach α for the total scores was adequate (AR = 0.85, PR = 0.8, and VH = 0.71). Performance score increased with operator skill level for all 3 procedures (AR, p = <0.001; PR, p = 0.008; and VH, p = 0.007). CONCLUSIONS Our low fidelity procedure-specific vaginal surgery models had adequate initial validity. Future research will investigate transferability of acquired skills to the operating room.
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Affiliation(s)
- Roxana Geoffrion
- University of British Columbia, Vancouver, British Columbia, Canada.
| | - Michael W Suen
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole A Koenig
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Yong
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Neeraj Mehra
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Maryse Larouche
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Terry Lee
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole J Todd
- University of British Columbia, Vancouver, British Columbia, Canada
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Pauls RN, Crisp CC, Oakley SH, Westermann LB, Mazloomdoost D, Kleeman SD, Ghodsi V, Estanol MV. Effects of dexamethasone on quality of recovery following vaginal surgery: a randomized trial. Am J Obstet Gynecol 2015; 213:718.e1-7. [PMID: 26032041 DOI: 10.1016/j.ajog.2015.05.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 04/16/2015] [Accepted: 05/28/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Dexamethasone is a corticosteroid with minimal side effects that may improve quality of recovery. We sought to evaluate standard use of this medication prior to vaginal reconstructive surgery. STUDY DESIGN This was a double-blind, randomized, placebo-controlled trial of women undergoing vaginal reconstructive surgery for pelvic organ prolapse. Patients scheduled for an intraperitoneal vaginal vault suspension, with general anesthesia and an overnight stay, were enrolled. The intervention arm received dexamethasone 60 minutes prior to surgery, and controls received placebo. Postoperative pain medications, antiemetics, and voiding trials were standardized. Our primary outcome was the difference in Quality of Recovery (QoR-40) scores on postoperative day 1. Secondary measures included Postoperative Nausea and Vomiting Intensity scores, and visual analog scales for nausea/vomiting, and pain. Our power calculation demonstrated 31 subjects in each group would be necessary to document difference in QoR-40 scores; to allow for attrition, a goal of 74 subjects was set. RESULTS Seventy-four women were enrolled and randomized. Two withdrew, 9 were excluded, and 63 were analyzed (36 placebo, 27 dexamethasone). The mean age was 63 years. No significant differences were noted among demographics other than American Society for Anesthesiologists class; there were greater numbers of dexamethasone subjects that were class 3 (5 vs 11; P = .030). Postoperatively, more patients in the placebo group required promethazine as a rescue antiemetic for control of their nausea/vomiting (11 vs 2; P = .029). Placebo subjects also failed their voiding trials more frequently, which remained following a logistic regression controlling for suburethral sling (30 vs 15; P = .037). Regarding the QoR-40 following surgery, the emotional state domain declined less in dexamethasone patients (-14.3, interquartile range [IQR], 16.8 vs -4.6, IQR, 20.1; P = .042), indicating better symptoms. Whereas pain scales were similar, the visual analog scales for nausea/vomiting was lower in dexamethasone subjects (0.7; IQR, 4.1 vs 0.4; IQR, 1.4; P = .042). Postoperative Nausea and Vomiting Intensity scores were not significantly different; nevertheless, twice as many placebo subjects had severe range symptoms (4 vs 2; P = .47). No adverse effects from the dexamethasone were noted. CONCLUSION Use of dexamethasone prior to vaginal reconstructive surgery was associated with less nausea/vomiting and need for antiemetics as well as greater success with voiding trials. Furthermore, quality of recovery was enhanced, suggesting use of dexamethasone should be considered for these patients.
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Glavind K, Larsen T, Lindquist ASI. Sexual function in women before and after surgery for pelvic organ prolapse. Acta Obstet Gynecol Scand 2014; 94:80-5. [PMID: 25287151 DOI: 10.1111/aogs.12524] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 09/30/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate sexual function in women before and after surgery for pelvic organ prolapse (POP) using native tissue repair. DESIGN A prospective observational study. SETTING Danish university hospital, between December 2008 and May 2010. POPULATION Eighty-one patients who had a POP operation with native tissue repair performed. METHODS The patients completed a validated Danish questionnaire on prolapse, the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire - 12 Short Form (PISQ-12-SF), and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF) before undergoing surgery and six months postoperatively. MAIN OUTCOME MEASURES Differences in PISQ-12-SF measures six months after the operation in different types of POP operations. RESULTS Preoperatively, the PISQ-12-SF score (mean ± SD) was 35.2 ± 4.6 and postoperatively 38.3 ± 3.9, giving a significant difference of 3.0 ± 3.8. (p < 0.05). Thirty-seven women (72%) improved their PISQ-12-SF score postoperatively, nine (18%) had an equal score, and five (10%) reported a lower score. There was no significant difference in the PISQ-12-SF scores between different operations. The ICIQ-UI-SF showed an overall improvement in incontinence postoperatively with a small correlation to PISQ-12-SF. CONCLUSIONS The majority of patients who undergo operation for different kinds of POP using native tissue repair, experience an improvement in their sexual life postoperatively. Most women with preoperative urinary incontinence experienced cure or improvement after POP surgery.
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Affiliation(s)
- Karin Glavind
- Department of Gynecology and Obstetrics, Aalborg University Hospital, Aalborg, Denmark
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Yuan L, Zhou H, Zhang H, Tang H, Chen M, Liu X, Xu C, Yao L. Constructing predictive models for vaginal surgery in patients with noninvasive gynecological conditions. Acta Obstet Gynecol Scand 2014; 93:935-40. [PMID: 24946854 DOI: 10.1111/aogs.12443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 06/08/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop predictive models for vaginal operative route selection based on clinical variables that can be easily assessed preoperatively in patients with noninvasive gynecological conditions. DESIGN Retrospective study. SETTING University Hospital. POPULATION Women with routine gynecological surgeries via different approaches. METHODS The medical records of 315 women without prolapse and undergoing hysterectomy, adnexal cystectomy or myomectomy were reviewed. Multiple logistic regression analysis was used to identify factors associated with the vaginal approach for each procedure. Predictive models were generated and optimal cut-off points were identified using the receiver operating characteristic curve. MAIN OUTCOME MEASURES Predictive models for different vaginal surgical procedures. RESULTS For hysterectomy, the patient's body mass index, dysmenorrheal complaints and uterine size were identified as negative predictors for vaginal hysterectomy, whereas previous vaginal delivery was positive. For adnexal cystectomy, adnexal pathology was a negative predictor, whereas previous vaginal delivery and ovarian cyst size were positive. For myomectomy, the body mass index and number of fibroids were negative predictors while previous vaginal delivery was positive. All three models were able to predict the vaginal procedures undergone by women and the areas under the curve were 0.88, 0.95 and 0.92, respectively. Each optimal model cut-off value (logit(p) = 0.53, 0.36, 0.73) resulted in good sensitivity (92.3%, 100% and 87.5%, respectively) and specificity (77.8%, 88.6% and 90.9%, respectively). CONCLUSION These predictive models, which used clinical variables that can be easily assessed preoperatively, may help surgeons to select candidates for different vaginal procedures.
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Affiliation(s)
- Lei Yuan
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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