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Background: Lower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy., Objective: The primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy., Study Design: This was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t -test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios., Results: A total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m 2 (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48-160.38; P =.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05-23.19; P =.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21-8227; P =.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury., Conclusion: Although lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.

Objective: To develop a stepwise approach to robotic assisted excision of cesarean scar pregnancy (CSP) with metroplasty., Methods: This illustrative video presentation demonstrating CSP, the criteria for ultrasound diagnosis, and a step-by-step approach for robotic assisted excision of CSP and multi-layer hysterotomy closure at a tertiary medical center., Results: Robotic assisted resection is a safe and feasible method to treat cesarean scar ectopic pregnancies. Key ultrasonographic characteristics of CSP are highlighted to facilitate its diagnosis, thus allowing for early intervention with a minimally invasive surgical treatment as necessary. Our patient was a 30-year-old gravida 2 para 1 woman with a history of 1 prior-term low transverse cesarean delivery, who presented with vaginal bleeding in the first trimester and was ultimately diagnosed with CSP. After unsuccessful methotrexate therapy, the patient underwent an uncomplicated robotic assisted excision of her CSP and metroplasty in 2 layers using a stepwise approach: Step 1-Creation of a bladder flap; Step 2-Isolation and excision of CSP; Step 3-Hysterotomy closure in 2 layers; and Step 4-Hysteroscopy., Conclusion: When diagnosed late, cesarean scar ectopic pregnancy can cause a significant hemorrhage from rupture. Early radiologic diagnosis does not only indicate minimally invasive surgery as a treatment option but also assists with related surgical planning. This video demonstrates a stepwise approach to the robotic assisted excision of CSP with metroplasty. With these 4 simple steps, surgical procedure can be safe and efficient.

Objective: To demonstrate a unique presentation and surgical treatment of a posterior uteroperitoneal fistula with excision of the fistula tract and repair in multiple layers., Design: Illustrative video presentation. A case report is used to describe potential causes of an uteroperitoneal fistula found in a patient during evaluation of secondary infertility and to highlight surgical technique and management using the principles of fistula repair through a minimally invasive approach. The Institutional Review Board reviewed this video article and it was deemed "not human subject research.", Setting: Tertiary medical center., Patient(s): A 33-year-old G1P1001 woman with a history of a cesarean section presented with secondary infertility, pelvic pain, and dysmenorrhea and was found to have a posterior uteroperitoneal fistula at the time of hysterosalpingography., Intervention(s): The patient underwent an uncomplicated robot-assisted laparoscopic excision of a posterior uteroperitoneal fistula with the use of careful dissection of the fistula tract, continuous reassessment, and tension-free closure in layers., Main Outcome Measure(s): Preoperative diagnosis and surgical management displaying intraoperative techniques for robot-assisted excision of fistula tract and repair of defect., Result(s): The patient underwent robot-assisted operative laparoscopy that revealed a 4-cm mass on the right posterior aspect of the uterus independent from her adnexa. Concomitant hysteroscopy revealed normal endometrium without an evident fistula. During chromopertubation, extravasation was seen into the peritoneal cavity from this mass. The mass and fistula tract were excised without a connection found from her cesarean scar, and reconstruction was performed in multiple layers. Endometriotic lesions were noted intraperitoneally in locations distant from the mass. The patient had significant improvement in her symptoms after surgery., Conclusion(s): We present a unique case of a suspected spontaneous posterior uteroperitoneal fistula in the presence of endometriosis without evidence of a connection to her prior hysterotomy scar. Possible etiologies include an undiagnosed, unrepaired hysterotomy extension or a result of chronic inflammation from deep infiltrating endometriosis. Adverse effects on fertility from uteroperitoneal fistulas may be due to disruption of sperm function or endometrial quality secondary to presence of old blood products sequestered in the fistula or due to resultant inflammation from the same. As in this video case, successful treatment of symptoms resulting from an uteroperitoneal fistula requires removal of the fistula tract. The constellation of pelvic pain, dysmenorrhea, postmenstrual bleeding, and infertility should raise suspicion for an uteroperitoneal fistula., (Published by Elsevier Inc.)

Objective: To demonstrate a simple, stepwise strategy for robot-assisted abdominal cerclage placement before pregnancy., Design: Demonstrative video presentation. Surgical footage surrounding a case report is used to describe a four-step technique for robot-assisted abdominal cerclage placement in women with recurrent pregnancy loss or other anatomic variants before pregnancy. This video article was reviewed by the Investigational Review Board and further investigation was waived because the study was "not considered human subject research.", Setting: Tertiary medical center., Patient(s): A 38-year-old G4P0220 (Gestations: 4, Term deliveries: 0, Preterm deliveries: 2, Abortions: 2, Living children: 0) with a history of two second trimester losses who had failed a prior history-indicated transvaginal cerclage (Fig. 1)., Intervention(s): The patient underwent an uncomplicated robot-assisted abdominal cerclage using a four-step strategy: Step 1, create the bladder flap; Step 2, identify pertinent anatomy; Step 3, place the cerclage; and Step 4, hysteroscopy., Main Outcome Measure(s): Intraoperative technique presenting a four-step method to ensure successful robot-assisted abdominal cerclage placement., Result(s): Robot-assisted abdominal cerclage is a safe, viable alternative to traditional abdominal cerclage placed via laparotomy. This video outlines four critical steps to facilitate placement and decrease patient morbidity. This patient did well operatively without increased blood loss or operative time and was discharged home on postoperative day 1. She went on to have a successful future pregnancy and currently is scheduled for an elective cesarean section at term., Conclusion(s): Abdominal cerclages significantly improve pregnancy and neonatal outcomes in women who previously have failed transvaginal cerclage. Robot-assisted abdominal cerclage placement allows a minimally invasive approach with enhanced dexterity and better visualization for the surgeon compared with conventional laparoscopy or laparotomy, as well as decreased pain and shorter recovery time for patients. This video demonstrates placement of a robot-assisted abdominal cerclage in a patient with recurrent pregnancy loss using a simple four-step strategy to ensure successful, correct, and easy placement. To our knowledge, this is the first video demonstrating a stepwise approach to robot-assisted abdominal cerclage placement., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)