Renal Hilum Injury with Veress Needle

Introduction

Since the advent of laparoscopy, the ideal first-port entry technique has not yet been determined. Use of the Veress needle at Palmer's point, although safe in practice under skilled physicians, is not without risk of complications.

Case Description

A female patient with prior abdominal surgeries underwent a laparoscopic surgery for a nonmalignant indication. Intraoperative complications included hemodynamic instability and gross hematuria. The patient was ultimately stabilized, and imaging after the case revealed a hematoma formation around the left kidney with evidence of renal hilar injury.

Discussion

The laparoscopic surgeon must be aware that blind Veress needle entry has inherent risk for injury of retroperitoneal structures including the renal system. Particularly if hemodynamic instability is noted after abdominal entry at any site, physicians should have a low threshold for investigation, including by laparotomy if necessary.

The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult

PURPOSE OF REVIEW

Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic disorders. To date, no formal recommendations have been made in defining a referral system for MIGS. This article reviews the evidence regarding common disorders and procedures and their outcomes, and posits a basis for MIGS referral.

RECENT FINDINGS

In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes, and therefore, benefit from the skills of MIGS subspecialists: fibroids - at least five myomas, myoma size at least 9 cm, and suspected myoma weight at least 500 g; endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; hysterectomy - uteri at least 250 g or 12 weeks estimated size, at least three prior laparotomies, obesity, and complex surgical history with suspected adhesive disease.

SUMMARY

A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case-Control Study

OBJECTIVE

To identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion.

MATERIALD AND METHODS

This is a case-control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion.

RESULTS

In total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m² (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m² (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]).

CONCLUSION

Smoking status, age under 55 years, BMI below 30 kg/m², fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Perioperative Outcomes of Combined Gynecologic Oncology and Urogynecologic Surgeries

Background: Many women diagnosed with a gynecologic malignancy may have coinciding urogynecologic complaints, such as pelvic organ prolapse (POP) and/or urinary incontinence, with approximately 35% reporting moderate to severe symptoms. Recent National Surgical Quality Improvement Program (NSQIP) database inquiries of gynecologic cancer cases found only 2.3-2.4% of women undergoing interventional surgery for gynecologic malignancy also had a procedure for pelvic organ prolapse urinary incontinence (POPUI), and those combination cases did not show significant increase in postoperative risks. The purpose of our study is to review our cases of gynecologic cancer that underwent concomitant urogynecologic procedures and compare their perioperative outcomes to gynecologic cancer cases without concomitant urogynecologic procedures. Methods: A retrospective cohort study conducted at a teaching hospital included 29 gynecologic oncology patients who underwent robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Controls underwent standard staging procedure and were compared to women with concomitant pelvic floor dysfunction that underwent additional laparoscopic uterosacral ligament suspension for apical suspension and a sling for stress urinary incontinence (SUI). The primary outcome was operative time, defined as documented total operative time and robot console time. Secondary outcomes include delta hemoglobin, hospital length of stay, readmission rate, total pain medication, urinary retention and discharge with foley. Results: The combined case group had longer total procedure time duration (301 minutes versus 210 minutes, p-value < 0.0001), with comparable mean console time (178 minutes versus 160 minutes; p = 0.1456). Blood loss estimated by mean percent difference of Hgb showed moderate conditional dependence on surgical case (22.2% cases versus 14.9% controls, p-value 0.04). Combined cases resulted in 76.9% of subjects discharged with a foley catheter compared to none in controls (p-value < 0.0001). Otherwise, there was no difference in the other perioperative outcomes between the two groups. Conclusion: With appropriate counseling and clinical judgement, combined urogynecologic and gynecologic oncologic surgeries can be performed to improve a patient’s quality of life (QOL) with minimal increase in perioperative morbidity.

Robotic Repair of Supratrigonal Vesicovaginal Fistula with Sigmoid Epiploica Interposition

Introduction and Hypothesis:

In the United States, vesicovaginal fistula (VVF) most often results from gynecologic surgery causing significant morbidity and distress to both the patient and surgeon. The use of tissue interposition at time of primary repair has been advocated to decrease the risk of recurrence. The aim of this study is to describe our experience with interposition of sigmoid epiploica during robotic extravesical repair of supratrigonal VVF.

Methods:

This is a retrospective case series from June 2015 to September 2016. Features of the surgical technique include 1) cystoscopic ureteral catheterization, 2) cannulation of the fistula, 3) mobilization of the bladder from the vagina, 4) removal of the epithelialized edges of the fistulous tract, 5) single-layer closure of the vagina, 6) tension-free layered closure of the bladder, 7) retrograde fill of the bladder to ensure water-tight repair, 8) interposition of sigmoid epiploica appendage(s), and 9) prolonged bladder drainage with indwelling transurethral catheter.

Results:

In total, 5 women underwent successful robotic VVF repair with epiploic appendage interposition. Mean surgical time was 218 minutes with an average console time of 147 minutes and an estimated blood loss of 49 mL. Most the patients were discharged to home on postoperative day 1 with no untoward effects due to the epiploica interposition. There have been no recurrences to date.

Conclusions:

Robotic repair of VVF with sigmoid epiploica interposition is efficient and well tolerated. Use of this technique may increase the number of patients eligible for tissue interposition.

Influence of Morbid Obesity on Surgical Outcomes in Robotic-Assisted Gynecologic Surgery

Objective: The aim of this research was to estimate the impact of body mass index (BMI) on surgical outcomes in patients undergoing robotic-assisted gynecologic surgery. Materials and Methods: This study was a retrospective review of prospectively collected cohort data for a consecutive series of patients undergoing gynecologic robotic surgery in a single institution. BMI, expressed as kg/m2, was abstracted from the medical charts of all patients undergoing robotic hysterectomy. Data on estimated blood loss (EBL), hemoglobin (Hb) drop, procedure time, length of hospital stay, uterine weight, pain-medication use, and complications were also extracted. Results: Two hundred and eighty-one patients underwent robotic operations. Types of procedures were total hysterectomy with or without adnexal excision, and total hysterectomies with lymphadenectomies. Eighty-four patients who were classified as morbidly obese (BMI>35) were compared with 197 patients who had a BMI of<35 (nonmorbidly obese). For patients with BMI<35, and BMI>35, the mean BMI was 27.1 and 42.5 kg/m2 (p<0.05), mean age was 49 and 50 (p=0.45), mean total operative time was 222 and 266 minutes (p<0.05), console time 115 and 142 minutes (p<0.05), closing time (from undocking until port-site fascia closure) was 30 and 41 minutes (p<0.05), EBL was 67 and 79 mL (p=0.27), Hb drop was 1.6 and 1.4 (p=0.28), uterine weight was 196.2 and 227 g (p=0.52), pain-medication use 93.7 and 111 mg of morphine (p=0.46), and mean length of stay was 1.42 and 1.43 days (0.9), all respectively. No statistically significant difference was noted between the 2 groups for EBL, Hb drop, LOS, uterine weight, pain-medication use, or complications. The only statistically significant difference was seen in operating times and included docking, console, closing, and procedure times. There were no perioperative mortalities. Morbidity occurred in 24 patients (8%). In the morbidly obese group, there were 6 complications (7%) and, in the nonmorbidly obese group, there were 18 complications (9%). Conclusions: Morbid obesity does not appear to be associated with an increased risk of morbidity in patients undergoing robotically assisted gynecologic surgery. Morbid obesity is associated with increased procedure time, but otherwise appears to have no difference in outcomes. Robotic surgery offered an ideal approach, allowing minimally invasive surgery in these technically challenging patients, with no significant increase in morbidity. J GYNECOL SURG 30:81).

Pregnancy in a woman with uterine procidentia: a case report

BACKGROUND

Uterine prolapse in pregnancy is rare and can either occur during pregnancy or be present before the pregnancy. We present a case of a successful pregnancy in a patient with preexisting uterine procidentia.

CASE

A 44-year-old woman with a history of complete uterine prolapse presented with an unplanned pregnancy. Upon initial presentation at 15 weeks she had uterine prolapse with cervical elongation that protruded 10 cm past the introitus. The prolapse persisted until about 30 weeks, during which it was conservatively managed with bed rest, knee-chest positions and local treatment of the desiccated cervix with emollients. The patient had an uncomplicated vaginal delivery and underwent a vaginal hysterectomy, anterior-posterior repair and a sacrospinous ligament fixation a few months later.

CONCLUSION

Uterine prolapse in pregnant women with preexisting prolapse will probably resolve in the third trimester without treatment. An otherwise uncomplicated course and a vaginal delivery can be expected.

Triplet gestation outcomes in relation to maternal prepregnancy body mass index and weight gain

OBJECTIVE

To study prepregnancy maternal body mass index (BMI) and overall maternal weight gain in triplet gestations in relation to maternal and newborn outcomes.

STUDY DESIGN

This was a retrospective study of birth certificate data of all live-born triplet gestations occurring between 1999 and 2003 in an eight-county region in New York. An analysis of computerized birth certificate data for variables related to pregnancy and newborn outcomes was conducted, looking at neonatal birth weight, neonatal gestational age, and the occurrence of the maternal pregnancy complications of gestational diabetes, gestational hypertension, and preeclampsia.

RESULTS

In 56 triplet gestations studied, the prepregnancy BMI was not associated with mean newborn birth weights and gestational age at delivery. The total maternal weight gain was associated with increasing mean birth weight and higher gestational age at delivery. Pregnancy complications in triplet pregnancies of gestational diabetes and gestational hypertension were associated with prepregnancy BMI, but not maternal weight gain.

CONCLUSION

For triplet gestations, a normal prepregnancy BMI and a total gestational weight gain of at least 15.9 - 20.5 kg (35 - 45 lb) are associated with fewer pregnancy complications.

Decreased maternal serum inhibin-A in pregestational diabetic women: implication for adjustment

OBJECTIVE

To evaluate the effect of maternal pregestational diabetes on serum dimeric inhibin-A (DIA), 1 of the 4 markers of the quadruple screen.

STUDY DESIGN

The data were collected retrospectively from women with singleton pregnancies who had a quadruple screen drawn at 15-20 weeks of gestation in 2004-2006. A total of 84 women with pregestational diabetes were identified and their DIA values were compared with those of 100 nondiabetic pregnant women. We compared the mean multiples of the median (MoM) for DIA levels among diabetics, among nondiabetics and between the 2 types of diabetics. We also measured the degree of correlation between the quadruple screen markers and glycosylated hemoglobin (HbA1C).

RESULTS

The corrected mean MoM for DIA levels among diabetic patients was 0.85 (95% CI, 0.77-0.95) vs. 1.0 (95% CI, 0.93-1.09) in the nondiabetic control group (p = 0.02). The mean MoMfor DIA levels did not appear to differ between type 1 and type 2 diabetes, and there does not appear to be a correlation between the quadruple screen markers and HbA1C.

CONCLUSION

The DIA levels among pregestational diabetic women are lower than in the nondiabetic population, suggesting a need for adjustment.