Abstract:

Tension-free suburethral tapes have revolutionized the surgical treatment of female stress urinary incontinence (SUI). These tapes are inserted by way of a retropubic or transobturator route. The inside-out tension-free vaginal tape transobturator approach, or TVT-Obturator system (TVT-O®, Ethicon Women’s Health and Urology, Somerville, NJ), was developed ten years ago with the aim of minimizing the risk of urinary tract injuries associated with retropubic and outside-in transobturator tapes while reproducibly ensuring minimal tissue dissection. Cadaveric studies have shown that the anatomical trajectory of the TVT-O tape is strictly perineal and courses away from neighboring obturator and pudendal neurovascular structures. Several meta-analyses have shown similar SUI cure rates after retropubic and transobturator tape procedures. Yet, the transobturator route may be associated with less voiding dysfunction, blood loss, bladder perforation, and shorter operating time. The original TVT-O procedure was modified with the aim of reducing the incidence of postoperative groin pain as well as the rather theoretical risk of obturator nerve injury. This modified procedure, named TVTABBREVO ® (Ethicon Women’s Health and Urology, Somerville, NJ), utilizes a shortened, 12-cm−long polypropylene tape. In addition, perforation of the obturator membrane with the scissors and guide is avoided in order to reduce the depth of lateral dissection, and consequently, to maximize securing of the tape within the obturator muscular/aponeurotic structures. In a comparative anatomical study, it was indeed observed that the shorter tape traversed less muscular structures (with no or only a minimal amount of tape lying in the adductor muscles) than its original counterpart, while still consistently anchoring in the obturator membrane at a similarly safe distance from the obturator canal. In a single-center randomized clinical trial, after a 3-year minimum follow-up, the modified TVT-O procedure with a shorter tape and reduced dissection was found to be as safe and efficient as the primal procedure for treating female SUI, with less severe and frequent groin pain in the immediate postoperative period.

Authors:

David Waltregny, MD, PhD, Head of The Department of Urology University Hospital of Liège, Liège, Belgium Jean De Leval, MD, PhD, Consultant, Department of Urology University Hospital of Liège, Liège, Belgium

PMID: 23109075

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Abstract:

Traditional laparoscopic suturing and knot tying requires a steep learning curve and is often the rate-limiting step in performing advanced laparoscopic gynecologic surgical procedures. It is particularly challenging due to difficulties with tissue handling and needle control while performing the procedure on a two-dimensional screen, oftentimes at unfavorable suturing angles. Automated suturing devices have greatly simplified the process and allow less-experienced surgeons to safely and efficiently perform laparoscopic suturing and knot tying. The Endo Stitch™ (Covidien, Mansfield, MA) is a 10-mm singleuse suturing device that allows placement of multiple suture types during laparoscopic surgery, and simplifies the process of laparoscopic knot tying. The SILS™ Stitch (Covidien, Mansfield, MA) is based on the same technology as the Endo Stitch with the added advantage of articulation up to 75° and rotation up to 360°. This enables surgeons to operate in tight spaces during advanced laparoscopic procedures, and to reach tissues in their natural anatomical position rather than pulling or manipulating tissue into the suturing device. Newer technologies in laparoscopic surgery, such as the Endo Stitch and SILS Stitch, may allow gynecologic surgeons to expand their surgical repertoire of advanced laparoscopic procedures.

Authors:

Stuart Hart, MD, FACOC, FACS, Assistant Professor, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Director, USF Center For The Advancement of Minimally Invasive Pelvic Surgery, Medical Director, Tampa Bay Research and Innovation Center, USF Health Center For Advanced Medical Learning and Simulation (CAMLS) University of South Florida Morsani College of Medicine, Tampa, Florida

PMID: 23225593

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Abstract:

Endometrial ablation and hysteroscopic myomectomy and polypectomy are having an increasing impact on the care of women with abnormal uterine bleeding (AUB). The complications of these procedures include the late onset of recurrent vaginal bleeding, cyclic lower abdominal pain, hematometra and the inability to adequately sample the endometrium in women with postmenopausal bleeding. According to the 2007 ACOG Practice Bulletin, approximately 24% of women treated with endometrial ablation will undergo hysterectomy within 4 years.1 By employing careful cervical dilation, a wide variety of gynecologic resectoscopes, and continuous sonographic guidance it is possible to explore the entire uterine cavity in order to locate areas of sequestered endometrium, adenomyosis, and occult hematometra. Sonographically guided reoperative hysteroscopy offers a minimally invasive technique to avoid hysterectomy in over 60% to 88% of women who experience endometrial ablation failures.2,3 The procedure is adaptable to an office-based setting and offers a very low incidence of operative complications and morbidity. In addition, the technique provides a histologic specimen, which is essential in adequately evaluating the endometrium in postmenopausal women or women at high risk for the development of adenocarcinoma of the endometrium.

Authors:

Morris Wortman, MD, FACOG, Clinical Associate Professor of Gynecology, University of Rochester Medical Center Director, Center for Menstrual Disorders and Reproductive Choice, Rochester, New York

PMID: 23292675

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Abstract:

As technology has evolved, so has the ability to perform a hysterectomy in a minimallly invasive fashion. Currently, total laparoscopic hysterectomy has been further advanced with the advent of uterine manipulation devices that incorporate the use of a cupped colpotomizer. Unfortunately, many gynecologic surgeons lack the understanding of how to fully utilize such a surgical guide to facilitate development of the vesico-uterine reflection, skeletonize uterine vasculature, gain entry into the vagina, and subsequently close the vaginal cuff. Safe completion of these steps has the potential to minimize complications such as ureteral and bladder injury in addition to vaginal cuff dehiscence. The following technical review will address methods for the safe and effective use of various cupped colpotomizer devices during total laparoscopic hysterectomy.

Authors:

Tiffany Jackson, MD, Fellow, Minimally Invasive Gynecologic Surgery, Florida Hospital Celebration Health Celebration, Florida, Arnold P. Advincula, MD, FACOG, FACS, Professor of Obstetrics and Gynecology University of Central Florida College of Medicine, Medical Director, Gynecologic Robotics at Global Robotics Institute, Director, Celebration Health Endometriosis Center, Director, AAGL/SRS MIS Fellowship,Florida Hospital Celebration Health, Celebration, Florida

PMID: 23292676

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Abstract:

With an increasing number of cesareans and repeat cesarean deliveries, clinicians have started to realize the importance of adhesions after cesarean delivery. Adhesions develop more frequently and with increasing severity with each repeat cesarean, and are associated with increasing maternal morbidity especially bladder injury and increased delivery time. It appears that adhesion formation could be reduced with closure of the peritoneum, double-layer closure of the uterine incision, and the use of adhesion barrier. In many reports of adhesion formation after cesarean delivery, authors have used different methods to evaluate adhesions. We encourage clinicians to adopt a newly published site-specific classification of adhesions after caesarean delivery.

Authors:

Nouf Al-Asmari, MD, Fellow in Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada, Togas Tulandi MD, MHCM, FRCSC, FACO, Professor and Academic Vice Chairman of Obstetrics and Gynecology, Milton Leong Chair in Reproductive Medicine, McGill University, Montreal, Quebec, Canada

PMID: 23292673

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Abstract:

We report the resection of a vaginal septum while preserving the virginity of a 12-year-old girl with Herlyn-Werner-Wunderlich Syndrome (HWWS) having a didelphys uterus, obstructed hemivagina, and an ipsilateral renal agenesis with follow-up at 18 months. Successful resection of the vaginal septum with conservation of the hymenal ring and complete drainage of both the hematocolpos and the hematometra were achieved. Cyclic dysmenorrhea and pelvic pain were completely resolved on follow-up visits at 4, 6, and 18 months. Office hysteroscopy performed during the last follow-up visit revealed a patent vaginal vault without evidence of adenosis or recurrence of the vaginal septum. Vaginoscopy is a safe, convenient, and efficient diagnostic and therapeutic modality that can be used in the management of patients with an obstructed hemivagina. It maintains the patient's virginity and it is useful in patients with a restrictive vaginal opening or narrow vaginal canal. Furthermore, the hysteroscopic excision of the vaginal septum offers minimal risk of recurrence of the septal defect.

Authors:

Nassif Joseph, MD, Assistant Professor in Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon , Ali Al Chami, MD, Resident in Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon, Antoine Abu Musa, MD, Professor in Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon, Anwar H. Nassar, MD, Professor in Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon, Ahmad Kurdi, MD, Medical Student, American University of Beirut Medical Center, Beirut, Lebanon, Labib Ghulmiyyah, MD ,Assistant Professor in Obstetrics and Gynecology, American University of Beirut Medical Center,Beirut, Lebanon

PMID: 23315718

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Abstract:

The purpose of this study is to report on the surgical preferences of international surgeons in the performance of the sacrocolpopexy procedure. Invitations to complete this Internet-based survey were sent to 2,854 International Urogynecological Association (IUGA) members from December 2010 through February 2011. Questions were related to various aspects of the surgeons' techniques and preferences in the performance of a sacrocolpopexy procedure by the abdominal, laparoscopic, and robotic routes. Descriptive statistics are reported. A total of 235 members from six continents completed the survey. Ninety percent of the respondents perform sacrocolpopexy procedures in their practices, including abdominal (n = 177), laparoscopic (n = 92), and robotic (n = 48) procedures. Participants reported reduced blood loss, shorter hospitalization, and longer operative time during laparoscopic and robotic procedures compared with open abdominal sacrocolpopexy, but no differences were reported in overall major complications. Overall, surgical preferences and techniques of international surgeons for sacrocolpopexy were similar among responders, regardless of the surgical route performed.

Authors:

Renee Bassaly, DO, Assistant Professor, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Mona McCullough, MD, ME, Fellow, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Deana Hussamy, MD, Resident, UT Southwestern, Dallas, Texas, Katheryne Downes, MPH, University of Maryland, School of Public Health, Department of Family Science, Lennox Hoyte MD, MSEECS, Professor, USF College of Medicine, Director, Female Pelvic Medicine and Reconstructive Surgery, Director, Urogynecology and Robotic Surgery, Tampa General Hospital, Chief Medical Information Officer, USF Physician's Group, Stuart Hart, MD, FACOG, FACS, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Director, USF Center for the Advancement of Minimally-Invasive Pelvic Surgery (CAMPS), Medical Director, Tampa Bay Research and Innovation Center (TBRIC), USF Health Center for Advanced Medical Learning and Simulation (CAMLS), University of South Florida Morsani College of Medicine

PMID: 23315720

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Abstract:

Pelvic organ prolapse (POP) is a common problem requiring surgical correction in up to 19% of women. Abdominal sacrocolpopexy (SCP) is considered the gold standard treatment for apical POP and has been associated with lower rates of recurrent prolapse and dyspareunia compared with vaginal POP repair procedures. Total laparoscopic hysterectomy (TLH) with concurrent laparoscopic uterosacral ligament (USL) vaginal vault suspension provides a safe and effective alternative technique that has efficacy rates similar to abdominal SCP without the use of synthetic mesh. The uterosacral ligaments provide a strong supportive tissue for vaginal vault suspension that mimics the natural support system of the pelvic floor. The most challenging aspect of the TLH with laparoscopic USL suspension is laparoscopic suturing and intra/extracorporeal knot tying. Developing technologies such as robotics, automatic suturing devices, and new barbed suture materials are now providing simpler, alternative surgical techniques that will hopefully shorten operative times and increase adoption of this surgical procedure by gynecologists. With continued progress and refinement of this technique, the TLH with laparoscopic USL suspension may challenge the current standard of care for surgical treatment of POP.

Authors:

Britton Crigler, MD, Resident PGY-4, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine Tampa, Florida, Mark Zakaria, MD, Fellow in Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, USF Center for Advanced Medical Learning and Simulation (CAMLS) University of South Florida Morsani College of Medicine,Tampa, Florida, Stuart Hart, MD, FACOG, FACS, Assistant Professor, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Director, USF Center for the Advancement of Minimally Invasive Pelvic Surgery (CAMPS), Medical Director, Tampa Bay Research and Innovation Center (TBRIC), USF Center for Advanced Medical Learning and Simulation (CAMLS),University of South Florida Morsani College of Medicine,Tampa, Florida

PMID: 23225594

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