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Objective: To demonstrate the urodynamic and clinical effects of transvaginal polypropylene mesh repair (TVM) for severe cystocele with or without stress urinary incontinence (SUI).Methods: One hundred women with severe cystocele who underwent transvaginal cystocele repair using a tension-free polypropylene mesh were included in a retrospective study. A simultaneous transobturator tape (TOT) procedure was performed in 24 patients with concurrent urodynamic stress incontinence (USI). Postoperative follow-up examinations included urodynamic testing, pelvic organ prolapse quantification, and urogynecologic questionnaire.Results: Mean follow-up was 35 months (range, 13-68 months). At 3-6 months after surgery, 2 (8.3%) of the 24 patients with USI who had undergone TVM and TOT had persistent SUI. Of the 30 women with occult USI who had undergone TVM alone, 6 (20%) developed symptomatic SUI and 9 (30%) had asymptomatic SUI. Thirteen (28.3%) of the 46 patients without USI developed postoperative SUI. The 1-year results showed de novo SUI in 10 (10%) women, recurrent cystocele in 6 (6%), and mesh erosions in 5 (5%). Four (13.3%) of the 30 patients engaging in sexual activity had dyspareunia.Conclusion: TVM is effective and safe in patients with severe cystocele, but may have an impact on voiding and sexual activity. [ABSTRACT FROM AUTHOR]

Objective: To determine the pre-malignant and malignant potential of endometrial polyps and to assess whether different clinical parameters are associated with malignancy in the polyps of premenopausal women.Methods: The clinical records of operative office hysteroscopic and resectoscopic procedures for endometrial polyps in 417 premenopausal women who attended Baskent University were examined over a retrospective period of 30 months. Only premenopausal patients were included in the study.Results: In 97.8% of women, histology showed benign endometrial pathology. In 2.2% of women, pre-malignant or malignant conditions were found in the polyp. Polycystic ovary syndrome (PCOS) and the presence of 2 or more polyps were associated with significant pre-malignant or malignant changes.Conclusion: The presence of irregular vaginal bleeding was not a predictor of malignancy in the polyp. Premenopausal women with PCOS and those with 2 or more polyps had an increased prevalence of polyp malignancy. These groups of patients, whether symptomatic or not, should be evaluated by hysteroscopic resection of the polyps. [ABSTRACT FROM AUTHOR]

Objective: To compare the specific effects of 2 female sterilization methods: the modified Uchida technique and the application of silver clips.Methods: A total of 2198 women living in rural areas who were still of reproductive age but opting for sterilization were enrolled. The participants were randomly divided into 2 groups, and underwent sterilization by either modified Uchida technique or silver clips. Information on acceptability, operation conditions, effectiveness, adverse effects, and complaints was collected 3, 6, and 12 months after the procedure.Results: No significant difference in effectiveness, adverse effects or chief complaints between the 2 procedures was found. Differences in operative outcome, bleeding volume during the procedure, and operation time were found.Conclusion: A shorter operation time and less bleeding for the silver clip method indicated that female sterilization by this technique was as safe as that by modified Uchida technique. [ABSTRACT FROM AUTHOR]

Objective: To assess the advantages of a surgeon-controlled robotic endoscope holder in gynecologic minimally invasive solo-surgery as compared with conventional assistance with a second surgeon.Methods: One hundred gynecologic laparoscopies were consecutively allocated to surgery with either a robot as the surgical assistant or a conventional assistant surgeon. Total operation time, image stability, and frequency of corrective maneuvers of the camera, in addition to the surgeon's satisfaction regarding the ergonomics of the intervention, were recorded. All interventions were performed by the same surgeon. All laparoscopic surgery was classified as either easy or advanced surgery.Results: The image stability score was significantly higher (10 vs 7; P<0.001) and fewer corrective maneuvers of the robotic endoscope were necessary (1 vs 5; P<0.001) with the robotic laparoscope holder; in addition, the surgeon recorded a significantly higher satisfaction score for the ergonomics of the semi-active robot (10 vs 7; P<0.001).Conclusion: The robot does not prolong total operation time and increases the surgeon's comfort by improving image stability and laparoscope handling. It could provide major benefit, especially in complex gynecologic laparoscopic surgery. [ABSTRACT FROM AUTHOR]

Objective: To describe the surgical technique of uterine artery sparing robotic assisted radical trachelectomy (AS-RRT) for early stage cervical cancer.Methods: We used our experience with AS-RRT performed at the University of Wisconsin-Carbone Comprehensive Cancer Center, USA, to present a detailed description of the surgical technique.Results: The report details, step-by-step, our innovative surgical technique, supported by photos and illustrations. We also discuss potential difficulties with the surgical technique and offer solutions.Conclusion: Technically, the surgery is feasible and could be performed by any gynecologic oncologist who is skilled in radical pelvic surgery and the robotic system. The long-term obstetric and oncologic outcome of this technique would be expected to match the outcome of the other radical trachelectomy techniques in the published literature, but is yet to be fully elucidated. [ABSTRACT FROM AUTHOR]

Objectives: To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery.Options: Women undergoing pelvic surgery are at risk of developing abdominal and/or pelvic adhesive disease postoperatively. Surgical technique and commercial adhesion prevention systems may decrease the risk of postoperative adhesion formation.Outcomes: The outcomes measured are the incidence of postoperative adhesions, complications related to the formation of adhesions, and further intervention relative to adhesive disease.Evidence: Medline, EMBASE, and The Cochrane Library were searched for articles published in English from 1990 to March 2009, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, cohort studies, and meta-analyses specifically addressing postoperative adhesions, adhesion prevention, and adhesive barriers. Searches were updated on a regular basis and incorporated in the guideline to March 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery. Options: Women undergoing pelvic surgery are at risk of developing abdominal and/or pelvic adhesive disease postoperatively. Surgical technique and commercial adhesion prevention systems may decrease the risk of postoperative adhesion formation. Outcomes: The outcomes measured are the incidence of postoperative adhesions, complications related to the formation of adhesions, and further intervention relative to adhesive disease. Evidence: Medline, EMBASE, and The Cochrane Library were searched for articles published in English from 1990 to March 2009, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, cohort studies, and meta-analyses specifically addressing postoperative adhesions, adhesion prevention, and adhesive barriers. Searches were updated on a regular basis and incorporated in the guideline to March 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. [ABSTRACT FROM AUTHOR]

Objective: To present the experience of a single provider with total laparoscopic hysterectomy (TLH) for benign gynecological pathology in order to promote awareness of the feasibility and merits of this minimally-invasive procedure.Methods: An intention-to-treat prospective study was conducted in a suburban gynecological practice in Central Georgia, USA. The study data were collected over a 7-year period.Results: From March 2003 to December 2009, 623 total laparoscopic hysterectomies including 379 pure laparoscopic hysterectomies (without additional procedures) were performed and 12 patients were referred to a gyn-oncologist. The majority of our patients (93.6%) had a uterine weight of less than 500 g. The median operative time was 60 minutes for pure total laparoscopic hysterectomies. There were 14 intraoperative organ injuries of which 13 were repaired intraoperatively and no returns to the operation room within the first 24 hours. The average hospital charges for TLH were US $13,468 with an average length of stay of 1 day. The average charges for total abdominal hysterectomy were US $12514 with an average length of stay of 2.3 days.Conclusion: An advanced laparoscopist can replace the majority of inpatient total abdominal hysterectomies performed for benign indications with outpatient total laparoscopic hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To investigate the prevalence of newly diagnosed endometriosis in premenopausal women who requested a consultation with their general practitioner because of non-gynecological problems.Method: Participants in the study were invited to complete a questionnaire investigating the presence of pain symptoms and infertility. On the basis of the characteristics of these symptoms, some patients underwent gynecological examination and transvaginal ultrasound. Radiological examinations were performed when bowel or bladder endometriosis were suspected.Results: A total of 1291 women without a previous diagnosis of endometriosis were included in the study. On the basis of the symptoms, 108 women were referred to a gynecologist. After gynecological examination and transvaginal ultrasound, endometriosis was suspected in 51 women (47.2%). The diagnosis of endometriosis was confirmed by radiological investigations and/or surgery in 46 patients; the diagnosis of endometriosis was presumed in 2 other women but it was not confirmed by radiological investigations and/or surgery. The prevalence of endometriosis diagnosed by magnetic resonance imaging and/or surgery was 3.6% (46/1291).Conclusion: The prevalence of newly diagnosed symptomatic endometriosis in this study was at least 3.6%. A simple evaluation of symptoms (pain and infertility) that can be performed by a general practitioner facilitates the diagnosis of endometriosis. [ABSTRACT FROM AUTHOR]

Abstract: Reinfibulation is resuturing after delivery or gynecological procedures of the incised scar tissue resulting from infibulation. Despite the global fight against female genital mutilation/cutting (FGM/C), reinfibulation of previously mutilated or circumcised women is still performed in various countries around the world. A good estimate of the prevalence of reinfibulation is difficult to obtain, but it can be inferred that 6.5–10.4million women are likely to have been reinfibulated worldwide. Women who undergo reinfibulation have little influence on the decision-making and are usually persuaded by the midwife or birth attendant to undergo the procedure immediately following labor or gynecological operation. Although medicalization of reinfibulation may reduce its immediate risks, it has no effect on the incidence of long-term risks. Reinfibulation is performed mainly for the financial benefit of the operator, and cultural values that have been perpetuated for generations. Reinfibulation has no benefits and is associated with complications for the woman and the unborn child. Its medicalization violates the medical code of ethics and should be abandoned. International and national efforts should be combined to eradicate this practice. [Copyright &y& Elsevier]

Objective: To introduce an alternative approach to vaginoplasty using transretropubic traction (TRT).Methods: In this case series with 4 patients with complete vaginal aplasia, a plastic "olive" placed on the vaginal dimple was lifted by a mesh tape inserted through the space of Retzius and anchored to the anterior abdominal wall.Results: On day 8 postoperatively all patients had a reasonable vaginal size, 2.5 to 3 cm in width and 6 to 7.5 cm in length. The mean satisfaction scores were 86 points for the patients and 89 points for their husbands, who also reported a mean penetration score of 90 points.Conclusion: As a minimal-access and relatively simple operation, TRT vaginoplasty could be performed by trained gynecologists. Studies with larger populations are required to support this preliminary report. [ABSTRACT FROM AUTHOR]

Objective: To determine which adipocytokines are differentially expressed as a function of body mass index (BMI), to compare expression of adipocytokines in abdominal subcutaneous and omental fat, and to correlate these findings with serum levels, BMI, and parameters of insulin resistance.Methods: Serum and subcutaneous (sc) and omental (om) tissue were obtained from lean and obese ovulatory women undergoing gynecologic surgery. We determined adipocytokine expression in sc versus om abdominal fat and related this to increasing BMI.Results: Serum leptin was higher and adiponectin lower in overweight subjects. Adipocytokines had higher expression in sc abdominal versus om adipose tissue with the most significant difference observed for leptin (P=0.01). As BMI increased, sc leptin expression increased and adiponectin expression decreased. The leptin/adiponectin ratio correlated significantly with BMI (R=0.84, P=0.0001).Conclusion: Increased adipocytokine expression correlates with BMI. Abdominal sc tissue has greater adipocytokine expression overall. The serum leptin/adiponectin ratio is highly correlated with BMI. These data may help in our understanding of how obesity affects women in a variety of ways. [ABSTRACT FROM AUTHOR]

Objective: To report on the efficacy and safety of infracoccygeal sacropexy for the treatment of uterovaginal prolapse.Method: A retrospective analysis of 87 women who underwent an infracoccygeal sacropexy procedure, 53 receiving a multifilament and 34 receiving a monofilament tape.Results: The mean follow-up was 27 months. Postoperative perineal pain was reported by 7 women (10%), and dyschesia and dyspareunia were observed de novo in 4 (5%) and 5 women (6%), respectively. There were 5 cases (9%) of vaginal extrusion and 9 cases (18%) of prolapse recurrence in the multifilament tape group, and in the monofilament tape group there were no cases of vaginal extrusion and 4 cases (14%) of prolapse recurrence (P=0.79 for prolapse recurrence). The recurrence-free survival curves of the 2 groups were similar. Univariate analysis revealed no independent factors of recurrence.Conclusion: Although infracoccygeal sacropexy was found to be associated with few prolapse recurrences, complications were not rare. [ABSTRACT FROM AUTHOR]

Objective: To determine the indications for gynecologic surgery and the effect of surgery on dyspareunia and sexual intercourse frequency in menopausal women in Accra, Ghana.Method: Women who had gynecologic surgery between January 2005 and December 2007 were invited for an interview about dyspareunia and frequency of intercourse before and after surgery.Results: Of the 93 women interviewed who underwent hysterectomy, 29 (31.1%) had dyspareunia before surgery and 13 (14.0%) after (P=0.006). Of the 65 women who had benign tumors, before surgery 26 (40%) were sexually active, while after surgery 43 (66%) were sexually active (P=0.001). However, frequency of intercourse did not change for those with malignancies. The mean frequency of intercourse before surgery was 2.11 per week, compared with 2.46 per week after surgery (P=0.50).Conclusion: Gynecologic surgery reduced dyspareunia. More women became sexually active following surgery for benign but not malignant tumors, but the mean overall frequency of intercourse did not change significantly in the interviewed population. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare vaginal length after iliococcygeus fixation (ICF) and sacrospinous ligament fixation (SSLF). Methods: A retrospective cohort study was performed on patients undergoing ICF or SSLF. Sixty-seven patients were identified and, of these, only 46 had complete data sets, leaving 23 patients in either group eligible for study. Results: There were no significant differences in demographic data between the 2 groups. Mean vaginal length measurements were not significantly different before and after the ICF procedure (7.7±0.9 cm vs 7.6±0.8 cm, respectively; P =0.68). However, the mean vaginal length was significantly shortened following SSLF (7.9±0.8 cm vs 7.1±1.1 cm, P =0.001). The mean vaginal lengths preoperatively (7.7±0.9 cm vs 7.9±0.8 cm, P =0.51) and postoperatively (7.6±0.8 cm vs 7.1±1.1 cm, P =0.07) were similar. Conclusion: Iliococcygeus fixation does not significantly shorten vaginal length at the time of vaginal vault suspension, whereas the sacrospinous ligament fixation procedure does shorten vaginal length. [Copyright &y& Elsevier]

Objective: To compare infracoccygeal sacropexy (IS) and sacrospinous suspension (SS) for the treatment of uterine or vault prolapse.Methods: A randomized trial of 49 women assigned to either the IS group using IVS tape (n=24) or SS group (n=25). Concomitant hysterectomy and repairs were performed as appropriate. Evaluations included prolapse staging using the POP-Q system and validated questionnaires for symptoms (PFDI), quality of life (PFIQ), and sexuality (PISQ-12). The primary outcome measure was postoperative pain.Results: Patients' characteristics were similar in both groups. IS was quicker, easier, and less painful than SS (P<0.01). Hemorrhage or hematoma rates were similar. Neither rectal injury nor vaginal erosion occurred. Mean follow-up was 16.8 months. Prolapse cure rates, symptom scores, and quality of life were similar. Postoperative cystocele occurred in 4.8% of women after IS and 25% after SS (P>0.05).Conclusion: Infracoccygeal sacropexy is equivalent to sacrospinous suspension, with a decreased rate of postoperative pain and cystocele recurrence. [ABSTRACT FROM AUTHOR]

Abstract: Technological advancements have enabled miniaturization of the endoscope without significant compromise to either diagnostic or operative abilities. With a complement of instruments <5 mm in diameter, newer minimally invasive techniques have been developed to decrease the pain and trauma associated with surgical procedures. These advancements involve additional options for peritoneal access as well as facilitating diagnostic evaluation of the pelvis. Although the robustness and durability of the smaller instruments is an area of concern, a thorough understanding of the clinical advantages and disadvantages has the potential to improve patient outcomes. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the prophylactic use of dexamethasone for reducing postoperative nausea and vomiting (PONV) and analgesic use after gynecological laparoscopic surgery. Methods: In a prospective randomized, double-blind, placebo-controlled trial, 90 women received either intravenous placebo, 4 mg dexamethasone or 8 mg dexamethasone at the end of surgery. PONV and analgesic requirements were evaluated. Results: The rate of patients experiencing PONV within 24 h after anesthesia was 53% in the 4 mg dexamethasone group (P =0.3) and 20% in the 8 mg dexamethasone group (P =0.001), compared with the placebo group (63%). Requests for indomethacin to relieve intolerable pain were less in patients in the 8 mg dexamethasone group compared with the 4 mg dexamethasone (P =0.047) or placebo (P =0.029) groups. Conclusion: Prophylactic use of 8 mg dexamethasone is effective for reducing PONV and analgesic requirements after gynecological laparoscopic surgery. [Copyright &y& Elsevier]

Abstract: Objective: To assess the effectiveness and safety of interventions to reduce blood loss during myomectomy. Methods: Electronic searches of the Cochrane Library, MEDLINE, and EMBASE, between 1966 and 2006 for randomized controlled trials (RCTs). Results: We found significant reductions in blood loss with vaginal misoprostol (weighted mean difference [WMD] −149.00 mL, 95% confidence interval [CI] −229.24 to −68.76); intramyometrial vasopressin and analogues (WMD −298.72 mL, 95% CI −593.10 to −4.34); intramyometrial bupivacaine plus epinephrine (WMD −68.60 mL, 95% CI −93.69 to −43.51); and pericervical tourniquet (WMD −1870.00 mL, 95% CI −2547.16 to −1192.84). There was no evidence of effect in blood loss with myoma enucleation by morcellation and oxytocin. Conclusion: There is limited evidence from a few RCTs that some interventions may reduce bleeding during myomectomy. There is need for adequately powered RCTs to shed more light on the effectiveness, safety, and cost of different interventions to reduce blood loss during myomectomy. [Copyright &y& Elsevier]

Objectives: The combination of gynecologic and plastic surgery procedures in a single surgical setting is becoming increasingly common because it reduces the number of general anesthetics and shortens overall recovery time. The primary concern should be patient safety.Methods: A MEDLINE search from 1980 to 2007 was conducted. Articles addressing combined gynecologic surgery with one of the various plastic surgical procedures of the abdomen (abdominoplasty, panniculectomy, and abdominal liposuction) were reviewed. The authors' comprehensive approach to the management of these patients was evaluated.Results: A unique set of safety issues exists depending on the specific combination of procedures. A review of the literature is discussed, as well as recommendations for maximizing the aesthetic outcomes while optimizing patient safety. Preoperative planning, intraoperative concerns, and postoperative care are all addressed in detail.Conclusions: Using a team approach and employing the outlined strategies to minimize complications, combined plastic and gynecologic procedures can be performed safely in appropriate patients. [ABSTRACT FROM AUTHOR]

Objective: The repair of combined vesico-vaginal fistulas (VVFs) and recto-vaginal fistulas (RVFs) is challenging to both surgeon and patient. The multistage approach involves at least 3 surgical sessions, all associated with morbidity and sometimes with a colostomy procedure as well. The outcomes of the 1-stage approach were examined.Methods: Twenty patients aged between 16 and 38 years were recruited for a multicenter study conducted from March 2005 to August 2006. Prolonged obstructed labor was the cause of all fistulas. The VVFs were mainly midvaginal (60%), juxtaurethral (25%), and juxtacervical (15%). The RVFs measured between 1 and 3 cm, they were low in 70% of cases, and 1 was associated with fourth-degree perineal tear. Bowel preparation was performed in all patients prior to surgery. No patient underwent temporary colostomy.Results: Both VVFs and VVFs were successfully closed in all patients, as evidenced by the continence dye test.Conclusion: The combined repair relieves economic constraints and emotional challenges, and it accelerates restoration to health and social reintegration for women affected with both VVFs and RVFs. [ABSTRACT FROM AUTHOR]

Abstract: The paper presents two case studies to illustrate the complexity of repairing obstetric fistula (OF) with neourethral construction when complete circumferential destruction occurred. Using fictitious names, the author describes the personal story and contexts leading to OF development and depression, surgical options, and the prognosis of repair. These cases were documented at the Barhirdar Hamlin Fistula Center in Northern Ethiopia. [Copyright &y& Elsevier]

Abstract: Nigeria harbors an estimated 40% of all the women affected with obstetric fistulas today, and at the current rate of treatment in this country, it would take about 300 years to treat them if no new fistulas occurred. This situation obviously runs contrary to the ideals of the United Nations Millennium Development Goals and needs to be reversed. We reviewed the literature on fistula treatment in Nigeria to identify strategies and practices that, if adopted, would likely accelerate the pace of fistula repair and improve postoperative fistula care in this country. A comprehensive nationwide survey, a stronger political will and commitment of resources, a systematic postoperative care and follow-up, more fistula centers, and more fistula campaigns are necessary. Technically, the involvement of all surgeons trained in fistula repair and an experience-based postoperative management protocol will relieve the disease burden carried by women living with fistulas in Nigeria. [Copyright &y& Elsevier]

Objectives: To assess the efficacy of local infiltrative anesthesia with lidocaine hydrochloride in patients undergoing the surgical repair of a simple vesico-vaginal fistula.Methods: The study was carried out with 21 patients undergoing the repair of a simple midvaginal vesico-vaginal fistula. The patients' perception of pain was evaluated intraoperatively.Results: Most patients indicated that the anesthetic agent provided adequate analgesia, and all fistulas were repaired successfully without postoperative complications.Conclusion: Repairing simple vesico-vaginal fistulas is feasible with a local infiltrative anesthetic. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy and safety of the tension-free vaginal tape (TVT) and transobturator suburethral tape (TVT-O) procedures for the treatment of mild and moderate stress urinary incontinence (SUI).Methods: A total of 56 women were randomly selected to undergo the TVT-O or the TVT procedure. In some patients, vaginal repair or vaginal hysterectomy was done simultaneously for associated indications.Results: Mean blood loss and hospital stay duration were the same for the 2 groups, but mean +/- SD operative time was significantly shorter in the TVT-O than in the TVT group (16+/-4 min vs 27+/-6 min; P<0.001). On the second day following surgery a residual urine volume less than 100 mL was noted in 86% and 89% of the patients in the TVT-O and TVT groups, respectively; cure was achieved in 92.9% and 92.6% of the patients. No serious complications occurred in either group. Outcome was subjectively assessed, with the patients followed-up for a mean of 27.6 months.Conclusion: No significant differences in rates of cure, postoperative urine retention, or operative complications were found following the TVT-O or the TVT procedure. [ABSTRACT FROM AUTHOR]

Objectives: To compare the complications of three techniques used to pass the suture through the sacrospinous ligament when performing sacrospinous ligament fixation (SSLF): (1) the standard needle driver with direct visualization; (2) the Deschamps ligature carrier by palpation; and (3) the Miya hook ligature carrier by palpation.Materials and Methods: A retrospective chart review of 240 patients undergoing SSLF was performed. A standard needle driver with direct visualization was used for 46 patients; the Deschamps ligature carrier was used for 173, and the Miya hook for 21 patients. Intraoperative and postoperative complications were compared between the groups.Results: Twelve women (5%) had intraoperative and forty women (17%) had postoperative complications suspected directly from the suture placement. There was no statistically significant difference in the rate of total intraoperative complications among the three groups. The proportion of patients with postoperative complications that were felt to be directly related to the suture passage technique was significantly higher in the Deschamps group compared to the direct visualization group (18% vs 2%, P=0.002).Conclusion: Passing the suture through the sacrospinous ligament under direct visualization may result in less intra and postoperative complications. [ABSTRACT FROM AUTHOR]

Objective: To compare the clinical efficacy of 3 surgical procedures for central types of anterior vaginal wall defect.Methods: A total of 138 patients diagnosed with central types of anterior vaginal wall defect who underwent classic transvaginal repair (n=72), transvaginal repair with polypropylene mesh (n=28), and internal repair (n=38) were followed up for at least 1 year.Results: There were no differences in development of fever, vaginal erosion, detrusor overactivity, and voiding difficulty among the 3 groups, but the incidence of postoperative urinary tract infections was significantly higher in the polypropylene mesh repair group. The difference in preoperative and postoperative hemoglobin levels and wound infection incidence were significantly higher in the internal repair group. Moreover, the recurrence rate of the anterior vaginal wall defect was significantly higher at 1 year in the internal repair group.Conclusion: Transvaginal surgical repair seems to be more efficacious than internal surgical repair for central types of anterior vaginal wall defects. [ABSTRACT FROM AUTHOR]

Objective: To report the intra-operative and post-operative results of laparoscopically assisted balloon vaginoplasty, a new technique for management of vaginal aplasia.Methods: Eight women with vaginal aplasia due to Mullerian agenesis who were referred for apareunia, dyspareunia. All had a poor penetration score and sexual satisfaction score. A Foley's catheter was laparoscopically inserted in the space between the urethra and rectum. Gradual traction and distension were used to create a neovagina. Outcomes measured were intra-operative complications, post-operative complications, length of the neovagina and post-operative complications and sexual satisfaction score in both partners.Results: Mean operative time was 25.5+/-5.5 min. No operative complications were recorded. Pain scores ranged from zero to 30 points at rest and from 30 to 60 points during dressing, traction and distension. Penetration and satisfaction scores increased significantly after the operation.Conclusions: Balloon vaginoplasty is a simple, safe and satisfactory technique for management of blind vagina. [ABSTRACT FROM AUTHOR]

Objectives: To explore the relationship between severity of pelvic organ prolapse (POP), symptoms of pelvic dysfunction and quality of life using validated measures.Method: Baseline data from 314 participants in the Colpopexy And Urinary Reduction Efforts (CARE) trial were analyzed. Pelvic symptoms and impact were assessed using the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). PFDI and PFIQ scores were compared by prolapse stage and history of incontinence or POP surgery. Regression analyses were performed to identify other predictors of symptoms and impact.Results: Women were predominantly (90%) Caucasian and had mean age of 61 years. Women with stage II POP, especially those with prior surgery, reported more symptoms and impact than women with more advanced POP. There were no other significant predictors of symptoms or life impact.Conclusions: Women planning sacrocolpopexy with stage II prolapse and prior pelvic surgery reported more symptoms and quality of life impact than those with more advanced prolapse. [ABSTRACT FROM AUTHOR]

Objective: To evaluate surgical, long-term anatomic and functional results of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis.Methods: Retrospective analysis of 86 women treated at the Department of Gynecology and Obstetrics at the University of Verona, Italy. Data were analyzed based on surgical results and postoperative sexual satisfaction. Depth and diameter of the neo-vagina was determined. The characteristics of the neo-vaginal mucosa were investigated by vaginoscopy. Patients reported frequency, satisfaction, and any difficulties found at intercourse.Results: Functional success was obtained in 98.1% and anatomic success in 100%. In all patients, at 1 year, the mucosa was pink, trophic, and moist. Two fingers were introduced easily into the neo-vagina in all cases. All patients, which decided to have sexual intercourse, defined these as satisfying within 6 months.Conclusions: Laparoscopic procedure used in this study is simple, safe, and effective. Anatomical and functional results obtained suggest this laparoscopic procedure as the treatment of choice for this syndrome. [ABSTRACT FROM AUTHOR]

Abstract: The ongoing desire to improve hemostasis and efficiency during surgery is manifested in the rapid development of electrosurgical technology. These changes have brought about a wide variety of devices available to the practicing surgeon during both open and endoscopic cases. Depending on the instrument chosen, various clinical effects ranging from simple coagulation to the sealing of large vascular bundles are obtained. However potential pitfalls or complications also exist. A thorough understanding of the pros and cons of these technological advancements can improve the operative experience for both surgeon and patient. [Copyright &y& Elsevier]

Abstract: Menorrhagia remains a significant health issue for women worldwide. Traditionally hysterectomy has been the treatment of choice when excessive menstrual bleeding remains unresolved by hormonal manipulation. In an attempt to provide a less invasive alternative to hysterectomy, traditional techniques such as rollerball endometrial ablation were developed 20 years ago. Although extremely effective, they possessed the potential of significant intra-operative risks and their success depended on high technical proficiency of the surgeon. As surgery and technology evolved, second generation endometrial ablation devices were developed which demonstrated improved safety and efficacy rates that paralleled traditional treatments. Since 1997, the Food and Drug Administration (FDA) has approved five such devices for use in the United States. Each possesses a unique technology profile with supporting level I evidence that allows for the treatment of a wide variety of uterine anatomy. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate whether saline wound irrigation decreases the incidence of wound infection following abdominal gynecologic surgery. Method: In this prospective randomized study, 104 patients underwent wound irrigation before wound closure following abdominal gynecologic surgery and 102 patients did not. Results: There were no significant differences between the 2 groups in patient characteristics or in factors influencing the incidence of wound infection after abdominal gynecologic surgery. The incidence of wound infection was 10.6% among women who underwent wound irrigation and 9.8% among those who did not, and the difference was not statistically significant. Conclusion: Saline wound irrigation before abdominal wall closure is not helpful in decreasing the incidence of wound infection after abdominal gynecologic surgery. [Copyright &y& Elsevier]

Abstract: Hemorrhage continues to be a serious complication of both obstetrical and gynecologic surgeries. Physicians have used packing in cases of uncontrollable hemorrhage for many years, and this article reports on a modification of standard packing techniques that prevents some of the limitations of traditional packing. This technique was used in 1 patient after cesarean hysterectomy and 3 patients after debulking surgery for advanced gynecologic cancer. The pack consists of a wide piece of ribbon gauze and a Penrose drain. One end of the ribbon gauze is draped over a layer of surgicel (oxidized regenerated cellulose), while the rest is threaded through a 1-inch Penrose drain tightly folded several times to maintain pressure over the bleeding area. The other end of the Penrose drain, with the ribbon gauze visible within it, is inserted through a stab incision in the ipsilateral side of the lower abdomen. This technique allows for continuous bleeding assessment and easy removal of the gauze at bedside. [Copyright &y& Elsevier]

Objective: To evaluate the clinical characteristics, complications, and satisfaction scores of patients who underwent the Manchester operation.Methods: This retrospective observational study evaluated data from 204 women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004.Results: Mean age was 34.68+/-4.24 years and parity 2.47+/-0.96; 85.8% of the patients were premenopausal; 176 patients (86.28%) had grade 3 and 28 (13.72%) had grade 2 uterine prolapse; 95.1% of the patients had associated cystoceles and 51.3% had associated rectoceles; and 81.4% had urinary incontinence. Regarding early postoperative complications, 27 patients (13.23%) had febrile morbidity; retroperitoneal hematoma occurred in 1 patient (0.49%); urinary retention occurred in 45 patients (22.05%), and cervical stenosis occurred in 23 patients (11.27%). At 1 year, 1 patient had undergone abdominal hysterectomy because of unsuccessful cervical dilatation; and a mean of 3.6 years following the operation, 8 patients (3.9%) had undergone the tension-free vaginal tape procedure plus a vaginal hysterectomy for recurrent stress urinary incontinence and uterine prolapse. The mean satisfaction/acceptance score for the operation was 8.52+/-2.13 (range, 2-10).Conclusion: A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus. [ABSTRACT FROM AUTHOR]

Abstract: The concept of delivering health services at a distance, or telemedicine is becoming an emerging tool for the field of surgery. For the surgical services, telepresence surgery through robotics is gradually being incorporated into health care practices. This article will provide a brief overview of the principles surrounding telemedicine and telepresence surgery as they specifically relate to robotics. Where limitations have been reached in laparoscopy, robotics has allowed further steps forward. The development of robotics in medicine has been a progression from passive to immersive technology. In gynecology, the utilization of robotics has evolved from the use of Aesop®, a robotic arm for camera manipulation, to full robotic systems such as Zeus®, and the daVinci® surgical system. These systems have not only been used directly for a variety of procedures but have also become a useful tool for conferencing and the mentoring of surgeons from afar. As this mode of technology becomes assimilated into the culture of surgery and medicine globally, caution must be taken to carefully navigate the economic, legal and ethical implications of telemedicine. Despite the challenges faced, telepresence surgery holds promise for more widespread applications. [Copyright &y& Elsevier]

Objective: To evaluate the efficacy of a peritoneal graft for the treatment of cervical aplasia.Method: Four patients with cervical aplasia who had a functioning endometrium and hematometra were recruited for this clinical trial. Through an abdominoperineal approach a plastic stent was inserted between the endometrial cavity and the upper part of the vagina; then, a graft of peritoneum was applied over the stent. In the absence of a vagina, grafts of skin or amniotic membrane were also used. The plastic stent was removed after 1 month in 2 patients and after 1 week in the 2 other patients.Result: After more than 1 year of observation the 4 patients had regular menstrual cycles with normal menstruation. Sonographic examinations also showed empty uterine cavities.Conclusion: Traditional gynecology textbooks recommend hysterectomy in cases of cervical aplasia. This report presents a new technique with 2 variations using a peritoneal graft. Although both variations were successful in the treatment of cervical aplasia in 4 women, more trials are needed to determine which one should be developed. [ABSTRACT FROM AUTHOR]

Objective: To compare the perioperative outcomes of women with an enlarged uterus (>or=250 g) who had abdominal and vaginal hysterectomies.Method: Retrospective study of the perioperative outcomes of 288 consecutive women with an enlarged uterus, of whom 200 underwent an abdominal hysterectomy and 88 a vaginal hysterectomy, all for benign gynecological conditions.Results: Among the perioperative complications, only the risk of ileus was significantly higher in the group that underwent abdominal hysterectomy. Although the need for blood transfusions was similar between the groups, mean perioperative hemoglobin change was significantly lower for women who had the abdominal approach. Vaginal hysterectomy shortened the length of hospitalization significantly but did not affect the operative time. All of these differences remained significant after adjusting for uterine weight (P<0.05). Baseline characteristics were similar between the groups, except for uterine weight.Conclusions: For women with a uterus weighing 250 g or more, vaginal hysterectomy shortens the hospital stay without significantly increasing perioperative morbidity when compared with the abdominal route. [ABSTRACT FROM AUTHOR]

Objective: A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension. Methods: A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro® (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter. Results: The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1–29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%). Conclusion: Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures. [Copyright &y& Elsevier]

Objectives: To evaluate the results of laparoscopic adnexectomy using an abdominal wall-lifting device compared to laparotomy. Methods: From February 1997 to December 2001, laparoscopic adnexectomy was performed in 68 cases of benign diseases in a university hospital. Three cases (4.4%) were converted to laparotomy due to poor visualization. The control group was a similar cohort of 65 patients who underwent the same procedures using laparotomy. Results: There were 59 ovarian cysts and six tubal pregnancies in each group. Mean analgesic used, hospital stay, recovery period and blood loss were 11.5 mg, 2.0 days, 1.0 week and 49 ml, compared with 151.8 mg, 4.0 days, 3.0 weeks, and 122 ml in the laparotomy group (P<0.0005). Mean operating times and hospital charges were 81.7 min and $293.9 (US), compared with 77.1 min (P=0.108) and $272.7 (US) (P=0.033) in the laparotomy group. No serious complications were found in either group. Conclusions: Gasless laparoscopic adnexectomy is a safe and effective technique to provide laparoscopic benefit with minimal increase in hospital charges. [Copyright &y& Elsevier]

Objectives: To evaluate and compare the surgical outcome between the innovative tension-free vaginal tape (TVT) and conventional pubovaginal sling (PVS) procedures using polypropylene mesh. Methods: Eighty consecutive women with urodynamic stress urinary incontinence (SUI), who chose to undergo either a TVT (n=23) or a PVS (n=57) procedure using polypropylene mesh based on financial consideration, were recruited for this study. The surgical results were analyzed and compared subjectively and objectively. Results: The mean follow-up interval was 23 months for the TVT and 20 months for the PVS procedure (P=0.062). Postoperatively, SUI (91.3% vs. 93.0%), concomitant urge symptoms (85.0% vs. 85.3%) and the negative impact of incontinence and urogenital distress on patients’ quality of life (79.8% vs. 77.8%) (77.4% vs. 68.8%) had improved markedly. After a multivariable logistic regression analysis, the treatment outcome of SUI was found to be independent of the main effects of patient age, parity, concurrent gynecological surgeries, intrinsic sphincter deficiency, previous failed incontinence surgeries, and concomitant urge symptoms. However, it was significantly related to treatment procedures (TVT vs. PVS) and their interaction with patient body mass index (BMI). Based on the fitted logistic model, we see that TVT performs better than PVS when BMI is less than 27.27 kg/m2, and the advantage of TVT decreases as BMI increases. Conclusion: Both TVT and PVS procedures using polypropylene mesh are effective treatment modalities for female SUI. However, TVT was not as effective in treating overweight or obese women as PVS. [Copyright &y& Elsevier]

Objective: To investigate the incidence and risk factors of symptomatic pulmonary thromboembolism (PTE) in patients following gynecologic surgery or cesarean section in Japan. Method: We examined the clinical records of all patients who have undergone gynecologic surgery or cesarean section at 32 hospitals affiliated with the Tohoku University Hospital between 1990 and 1999. Result: The total number of gynecologic surgical procedures and cesarean sections were 61 648 and 26 502, respectively. Twenty-five of the 88 150 (0.028%) patients developed clinical PTE. Among the PTE patients who underwent gynecologic surgery, 86% were more than 40 years of age, 36% were obese (BMI>25 kg/m2) and 43% had uterine body cancer. Among the PTE patients who underwent cesarean section, 36% were more than 35 years of age and 55% were obese (BMI>29 kg/m2). Conclusion: Risk factors in Japanese patients undergoing gynecologic surgery may include age and cancer of the uterine body; risk factors for the development of PTE following cesarean section may include age and obesity. [Copyright &y& Elsevier]

Objective: To determine if quinacrine sterilization (QS) is safe and effective in women at high risk for surgery.Methods: A trial was initiated at the Government Medical College in Patiala, India, in December 1993. Patient intake was terminated in July 1999 and the cut-off date for this analysis was March 31, 2003. Using a modified IUD inserter, seven 252 mg quinacrine pellets with 50 mg of diclofenac were transcervically inserted into the uterus. DMPA 150 mg was administered IM at the time of the first insertion as a back-up contraceptive. This same combination was inserted a month later. A total of 134 women underwent QS. Of these, 92 were considered to be at high risk for surgery, 27 were afraid of surgery or voluntarily opted for QS, and 15 had had failed surgical sterilization or surgery was found not to be technically feasible. Follow-up was scheduled for 1, 3, 6 and 12 months, and then annually after the second insertion or whenever side effects or complications were experienced.Results: Mean follow-up was 7.2 years. No pregnancies or serious complications were experienced.Conclusion: QS is a safe and effective option for women at high risk of surgical complications. [ABSTRACT FROM AUTHOR]

The medical world is facing increasing demands for improvement of the quality of life of women of all ages. This is not possible without overall improvement of the healthcare of females, and, in particular, of the quality of surgical treatment for gynecologic pathology. Positive changes are ensured by the active introduction of minimally invasive technologies into all spheres of gynecologic practices. There are almost no medical, demographic or technical limits for the application of endoscopy in gynecology, while the benefits it provides are extraordinary. The process of positive change towards minimally invasive surgery in operative gynecology should be supported and promoted by the medical community in every possible way. [Copyright &y& Elsevier]

Vesico-vaginal fistula remains a major public health issue in the developing world. Over 80% of cases result from neglected obstructed labour, and the condition may follow 1–2 per 1000 deliveries, with an annual worldwide incidence of up to 500 000 cases. The principles of investigation and treatment are reviewed in this paper, although national and international strategies aimed at prevention are much more important to the ultimate eradication of this devastating condition. Such strategies much include government recognition of fistulae as a major public health concern, improvement in the status of women in society, the extension of primary education particularly for girls, and affordable, accessible and acceptable services for all pregnant women. [Copyright &y& Elsevier]

Objectives: To assess which treatment modality has a better outcome: the use of an intrauterine contraceptive device or the Foley catheter balloon, for the adjunctive treatment of intrauterine adhesion (IUA) in patients presenting with infertility. Methods: In a 4-year initial period, patients with intrauterine adhesion were treated with the insertion of an intrauterine contraceptive device (IUCD) after adhesiolysis. In the next 4 years, a pediatric Foley catheter balloon was used after adhesiolysis instead of the IUCD. The postoperative treatment was the same throughout the 8 years. While the IUCD was removed after three consecutive withdrawal vaginal bleedings, the Foley catheter was removed after 10 days. Hysterosalpingography was repeated in all patients after the third withdrawal vaginal bleeding, and the procedure was repeated if the intrauterine adhesion still persisted. The χ2-test was used for analysis. Results: There were 51 cases of IUA treated with the IUCD and 59 cases treated with the Foley catheter balloon. In the Foley catheter group, 81.4% of the patients had restoration of normal menstruation compared with 62.7% in the IUCD group (P<0.05). Persistent posttreatment amenorrhea and hypomenorrhea occurred less frequently in the Foley catheter group (18.6%) than in the IUCD group (37.3%) (P<0.03), and the conception rate in the catheter group was 33.9% compared with 22.5% in the IUCD group. The need for repeated treatment was also significantly less in the Foley catheter group. Conclusion: The Foley Catheter is a safer and more effective adjunctive method of treatment of IUA compared with the IUCD. [Copyright &y& Elsevier]

Objectives: To determine the incidence of incomplete ovarian removal during gynecologic surgery and correlate the risk of inadequate removal with the procedure chosen. Methods: This is a prospective observational study. Ovaries received during a 4-month period in the participating institutions were independently histologically evaluated. Gross inspection of the ovarian capsule, infundibulopelvic ligament, hilum and utero-ovarian ligament was assessed. Grossly close margins were confirmed histopathologically. Any margin with histologically confirmed ovarian tissue at the margin was interpreted as incompletely removed. Details of each surgical procedure were recorded for comparison. Results: Ovaries (n=174) from 94 patients were collected and 155 were evaluable. The overall incidence of incomplete ovarian removal was 6.5%. Of the 125 ovaries removed abdominally, 23 were laparoscopically assisted and 7 were vaginal; inadequate removal was documented in 5%, 9% and 29%, respectively (P=0.04). There was no relationship of inadequate resection by underlying pathologic diagnosis (P=0.25) or by institution (4.6% university hospital vs. 8.8% community hospital; P=0.29). Conclusions: Incomplete ovarian removal occurs and is related to surgical approach. A larger study is warranted to evaluate the role of pelvic pathology or surgeon experience as a risk for incomplete oophorectomy. [Copyright &y& Elsevier]

A woman presented with symptoms of salpingitis 7 months after delivery. Initially treated as pelvic inflammatory disease, the condition was revealed to be genital localization of miliary tuberculosis. [ABSTRACT FROM AUTHOR]