Women residing in Olmsted County (n ϭ 9,258) who underwent hysterectomy in 1965-2002, compared to... more Women residing in Olmsted County (n ϭ 9,258) who underwent hysterectomy in 1965-2002, compared to an equal number of age-and sex-matched community controls. Intervention(s): Observational study of the effect of hysterectomy for various indications on subsequent fractures. Main Outcome Measure(s): Fractures of any type, and at osteoporotic sites (e.g., hip, spine, or wrist) alone, as assessed by electronic review of inpatient and outpatient diagnoses in the community. Result(s): Compared with controls, there was a significant increase (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.13-1.29) in overall fracture risk among the women with a hysterectomy, but osteoporotic fracture risk was not elevated (HR, 1.09; 95% CI, 0.98 -1.22). Most hysterectomy indications were associated with fractures generally, although these were not often statistically significant. Only operations for a uterine prolapse were associated with osteoporotic fractures (HR, 1.33; 95% CI, 1.01-1.74). Oophorectomy was not an independent predictor of fracture risk (HR, 1.0; 95% CI, 0.98 -1.15). Hysterectomy does not appear to pose much long-term risk for fractures, but the association of fractures with surgery for uterine prolapse deserves further attention. (Fertil Steril 2007
Female pelvic medicine & reconstructive surgery, 2017
Accounting for selection bias, MMC is associated with decreased operative time, non-UTI morbidity... more Accounting for selection bias, MMC is associated with decreased operative time, non-UTI morbidity, and hospital costs to patients compared with sacrocolpopexy in treating posthysterectomy prolapse.
American Journal of Obstetrics and Gynecology, Feb 1, 2018
The purpose of this video is to demonstrate three different closed-techniques insertions of supra... more The purpose of this video is to demonstrate three different closed-techniques insertions of suprapubic catheters (SPC). Short term voiding dysfunction after pelvic surgery is a common occurrence that is managed with bladder drainage via a transurethral catheter (TUC) or suprapubic catheter. The declining use of the SPC has been attributed to its invasive nature through a suprapubic skin incision and the creation of a cystotomy. However, the cystotomy and skin incision are less than 1-cm wide and heal within 24 hours after removal of the catheter. When compared to TUCs, SPCs have been associated with fewer urinary tract infections, less urethral trauma, better patient satisfaction, and greater ease of management. Most early-mid career gynecologic surgeons have less experience with SPCs in their training and are thus less inclined to use it. As pelvic surgeons, we should have the ability to offer this option when indicated because SPC insertion, management, removal, and troubleshooting is not complicated. The goal of this video is to provide guidance for surgeons interested in learning to use SPCs for treating short term voiding dysfunction when indicated. MATERIALS AND METHODS: We will review the advantages and disadvantages of the SPC versus the TUC. Next, we will present 3 teaching videos; 2 split-screen (cystoscopic view/perineal view) followed by a single screen. The 2 split-screen videos will review the components, assembly and insertion of the Rutner balloon SPC and the Mac-Loc SPC respectively. The last video will demonstrate a Lowsley retractor assisted SPC insertion. CONCLUSION: Short term voiding dysfunction is a common occurrence after pelvic surgery. The selection of either a suprapubic or transurethral bladder drainage depends on the specific clinical scenario. The SPC is a useful tool for any pelvic surgeon's virtual toolbox. We hope this video provides some guidance for others to optimize their use of the SPC.
The use of graft tissues to supplement pelvic reconstruction is becoming more common. Many tissue... more The use of graft tissues to supplement pelvic reconstruction is becoming more common. Many tissues are being used including xenografts, allografts and autografts. There are no good data on the disposition of any of these grafts tissues after implantation in the human pelvis. OBJECTIVE: We evaluate the disposition of Pelvicol (porcine dermal graft) 12 months after implantation for rectocele repair. MATERIALS AND METHODS: Patients underwent rectocele repair alone or in combination with other pelvic reconstruction procedures. Pelvicol was used to reconstruct the rectovaginal septum. 12 months following the surgery, 8 patients were asked to participate in a biopsy study at the rectocele repair site. All patients participated on a voluntary basis and received compensation for their participation. A 3mm punch biopsy was taken from the repair site, incorporating full-thickness of the recto-vaginal septum. Care was taken to not injure the rectum. A sample of normal vaginal mucosa and a sample of Pelvicol were also studied for cross-reactivity of the collagen stains. Porcine and human collagen localizations were performed by immunoperoxidase staining using polyclonal rabbit anti-porcine and anti-human Type I/III collagen antibodies on a Vantana Benchmark automatic stainer. Porcine antibody was diluted 15 times and human antibody was diluted 10 times. RESULTS: Both porcine and human collagen were visualized in all 8 biopsies. These collagens were intermixed in the tissue samples. Both positive and negative control tissues stained appropriately with minimal cross reactivity of anti-porcine collagen antibody in normal human tissue or anti-human collagen antibody in the Pelvicol. CONCLUSIONS: This study demonstrates the persistence of Pelvicol 12 months after implantation and the in-growth of human collagen into the dermal matrix.
American Journal of Obstetrics and Gynecology, Mar 1, 2010
The purpose of this study was to compare complications from vaginal hysterectomy with abdominal h... more The purpose of this study was to compare complications from vaginal hysterectomy with abdominal hysterectomy in renal transplant recipients. STUDY DESIGN: Women who underwent renal transplantation then hysterectomy from 1966-2008 at Mayo Clinic, Rochester, MN, were identified. Data were collected about preoperative, intraoperative, and postoperative events. Main outcome measure was loss of allograft function; secondary outcomes included types of complications and treatment methods. RESULTS: Of 58 women with renal transplants, 42 women (72.4%) underwent abdominal hysterectomy. The most common indication for hysterectomy was menorrhagia (n ϭ 20; 34.5%). Overall, 24 women (41.4%) had complications, the most common of which were infection (n ϭ 15) and transfusion (n ϭ 8). Women who underwent abdominal hysterectomy were no more likely to have perioperative complications than were women who underwent vaginal hysterectomy (odds ratio, 1.25; 95% confidence interval, 0.38 -4.08). CONCLUSION: Although patients with renal transplants had perioperative complications, none of these complications led to renal graft loss. Hysterectomy can be considered in these patients when accompanied by diligent postoperative care.
Female pelvic medicine & reconstructive surgery, 2019
The aim of this study was to compare outcomes of vaginal hysterectomy between patients with and w... more The aim of this study was to compare outcomes of vaginal hysterectomy between patients with and without the following perceived contraindications to vaginal surgery: uterine weight greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Methods: Retrospective cohort of benign vaginal hysterectomies between 2009 and 2013 was obtained. Outcomes included uterine debulking, transfusion, intraoperative complications, length of stay, and Accordion grade 2+ postoperative complications. For each outcome, the association between the presence of each contraindication and the outcome was evaluated using univariate and multivariate logistic regression models. Results: Among 692 vaginal hysterectomies, 11% (76/691) had a uterine weight greater than 280 g, 11.3% (78/690) had no vaginal parity, 14.9% (103/690) had a history of cesarean delivery, and 37.7% (248/657) had a body mass index of 30 kg/m 2 or greater; 110 (15.9%) had 2 or more contraindications. Uterine debulking occurred in 146 women (21.1%), and both uterine weight greater 280 g (adjusted odds ratio, 39.2; 95% confidence interval, 18.4-83.5) and prior cesarean delivery (adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7) were significantly associated with an increased likelihood of uterine debulking after adjusting for age, hematologic disease, and preoperative diagnosis. None of the contraindications were significantly associated with need for a blood transfusion, presence of an intraoperative complication, length of stay greater than 2 days, or presence of an Accordion grade 2+ postoperative complication, which occurred in 2.7%, 2.5%, 14.0%, and 6.9% of all women, respectively. Conclusions: Vaginal hysterectomy can be safely performed with favorable outcomes, even in women with a uterus greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Our findings challenge several perceived contraindications to vaginal hysterectomy.
p = 0.002), and sterilizations (p ! 0.001) than the 2003 graduates. The above findings were uncha... more p = 0.002), and sterilizations (p ! 0.001) than the 2003 graduates. The above findings were unchanged when evaluating procedures for which the resident was the primary surgeon. Duty-hour restrictions have not adversely affected the operative experience of obstetrics and gynecology residents. No significant differences in the number of the spontaneous vaginal deliveries, abdominal hysterectomies, or vaginal hysterectomies performed were observed.
Journal of Pelvic Medicine and Surgery, Jul 1, 2005
Background: Congenital abnormalities and malformations are more frequent in the urinary tract tha... more Background: Congenital abnormalities and malformations are more frequent in the urinary tract than in any other system of the body. The present study was conducted to evaluate incidence of congenital anomalies in urogenital tract in infants and children. Subjects and Methods: The present study was conducted on 55 cases age ranged 6 months to 8 years of congenital anomalies of urogenital tract which were admitted in department of Pediatric surgery ward of Kamla Nehru hospital, Bhopal during 1 year period. Type of anamoly was also recorded. In all patients, thorough clinical examination was performed. USG was done in all cases to confirm the cases. Results: Out of 1500 pediatric admissions, 56 (3.6%) had anomalies in urinary tract. In males, maximum lesions were hyposposdias seen in 13 followed by VUR & PUV in 12 patients and phimosis in 6 and 1 case of diphallia was found. In females, maximum lesions were congenital hydronephnosis, pelvic kidney, horse shoe kidney, ectopic ureter and ectopia vesicae seen in 1 patient each. Increased frequency of micturition was seen in 16, urine through ureter opening was seen in 12, dribbling of urine in 15 and suprapubic swelling was observed in 8 cases. USG revealed congenital hydronephnosis in 2, PUJ obstruction in 2, pelvic kidney in 2, ectopia vesicae in 2, ureterocele in 2. Conclusion: Authors found that maximum cases were of Hyposposdias followed by VUR & PUV and phimosis.
Objective: To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorde... more Objective: To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorders with that in control subjects.
We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vagi... more We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vaginal hysterectomy, including tips for troubleshooting difficult cases such as: uterine procidentia, cervical elongation, and multiple prior cesarean sections. Methods Anterior cul-de-sac entry is a critical step in performing a vaginal hysterectomy. In this video, we review our approach to anterior entry in patients with normal anatomy, followed by a discussion of techniques that may be useful in cases with challenging anatomy. To start, we drain the bladder, set up exposure with Deaver retractors, and make a circumferential incision at the cervicovaginal junction. In cases with normal anatomy, using sharp, followed by broad blunt finger dissection, the vesicocervical space is opened, and the peritoneal reflection is identified and sharply entered. If this is not possible, additional techniques such cystoscopic bladder illumination, posterior entry first, securing pedicles with extraperitoneal ties, or additional sharp dissection may be utilized. With all techniques, proper intraperitoneal entry should be verified by the visualization of small bowel or fat. Conclusion This video reviews technical considerations for anterior cul-de-sac entry during vaginal hysterectomy in patients with normal anatomy and provides tips for troubleshooting challenging cases.
American Journal of Obstetrics and Gynecology, Mar 1, 2017
RESULTS: Dichotomous predictor variables for length, height, and width were calculated separately... more RESULTS: Dichotomous predictor variables for length, height, and width were calculated separately based on differential percentile scores and combined with age in a logistic regression analysis. The logistic regression model was statistically significant, c 2 (4) ¼ 299.825, p < 0.000. The model explained 80.5% (Nagelkerke R 2 ) of the variance in procedure type and correctly classified 94.6% of cases. Sensitivity was 85.3%, specificity was 98.1%, positive predictive value was 94.57%, and negative predictive value was 94.55%. This created a predictive weighted index incorporating age with length, height, and width. Age >50 years counts as one point, while length (>11 cm), height (>8 cm), and width (>6.9 cm) each count for 3 points resulting in a potential scale range of 0 to 10 points. An index score of 4 or higher suggests the need for an alternative to vaginal extraction (94.5% of the current sample). Factoring in patient parity or uterine volume to the equation did not statistically influence the predictive power of the model. We have created a simple model for predicting vaginal extraction of specimens during laparoscopic hysterectomy. In the current environment, with morcellation under scrutiny, this may enable clinicians to better anticipate the need for an alternate route of specimen delivery and counsel patients accordingly.
American Journal of Obstetrics and Gynecology, Mar 1, 2017
retention or obstructive voiding symptoms, complex urinary incontinence symptoms, complicated low... more retention or obstructive voiding symptoms, complex urinary incontinence symptoms, complicated lower urinary tract surgical history or conditions increasing the risk for poor bladder compliance or vesicoureteral reflux. An example of a normal video urodynamic study is described to demonstrate important techniques and to show the five points at which images are generally obtained. Examples of interesting study findings are discussed. Findings include bladder diverticula, detrusor overactive with leakage, poor bladder compliance, vesicoureteral reflux, stress incontinence, detrusor external sphincter dyssynergia, open bladder neck, and urethral diverticulum. CONCLUSION: Video urodynamics has several important advantages over conventional urodynamics for the evaluation of patients with lower urinary tract symptoms. It gives the clinician simultaneous functional and anatomic views of the urinary tract. While this can be of great benefit for specific patient presentations, the advantages do not come without potential risks. Financial costs and risk of radiation exposure must be weighed against the benefit. Nevertheless, in complicated patients, as illustrated here, video urodynamics may be invaluable in evaluating complex lower urinary tract dysfunction.
Journal of Minimally Invasive Gynecology, Mar 1, 2015
Objective: To describe and demonstrate an alternative surgical laparoscopic approach to removing ... more Objective: To describe and demonstrate an alternative surgical laparoscopic approach to removing polypropylene mesh embedded and perforating the bladder by way of robotic assistance. Description: Mid-urethral slings (MUS) are currently the most common surgical procedure for the treatment of female stress incontinence. Although retropubic MUS complications are uncommon, they can occur. Of these, intraoperative bladder perforation is the most common with an incidence of 3.5-6.6%. When diagnosed, polypropylene mesh compromising the integrity of the bladder must be completely removed. Methods: Following delayed recognition of a through-and-through perforation of the bladder by passage of a retropubic midurethral sling, we elected to proceed with a robotic-assisted laparoscopic retropubic dissection and transvesical resection of the embedded sling with intraoperative cystoscopy and ureteral stent placement. Results: Patient underwent a successful robotic-assisted laparoscopic resection of an embedded retropubic MUS. The operation was uncomplicated. Blood loss was 50 ml and the total operative time was 2 hours and 40 minutes. The patient tolerated the procedure well and was discharged home the following day with an indwelling Foley catheter. Her perioperative course was uncomplicated and she went on to have complete resolution of her presenting symptoms and follow-up office cystoscopy revealed a normal appearing bladder. Conclusion: Given the increasing number of robotic-assisted laparoscopic procedures and expertise with robotic surgery in the U.S., a robotic-assisted laparoscopic procedure may be an attractive alternative to managing complications related to perforation or erosion by synthetic mesh.
Pelvic organ prolapse (POP) is a prevalent condition that can have a significant impact on a pati... more Pelvic organ prolapse (POP) is a prevalent condition that can have a significant impact on a patient's quality of life. Treatment is indicated for patients who are symptomatic or those that have associated bladder, bowel, or sexual dysfunction. The decision to proceed with conservative management or surgery is based on multiple factors, including symptoms, treatment goals, risk and benefits of intervention, sexual functioning, and medical comorbidities. Overall, the lifetime risk of a woman undergoing surgery for POP is 13%. Transvaginal surgical approaches include reconstructive and obliterative procedures. Native-tissue repair has been demonstrated to be a safe and effective treatment option for addressing POP and is an important skill set for gynecologic surgeons. This review discusses the different techniques available for transvaginal POP repair. ( J GYNECOL SURG 39:12
Women residing in Olmsted County (n ϭ 9,258) who underwent hysterectomy in 1965-2002, compared to... more Women residing in Olmsted County (n ϭ 9,258) who underwent hysterectomy in 1965-2002, compared to an equal number of age-and sex-matched community controls. Intervention(s): Observational study of the effect of hysterectomy for various indications on subsequent fractures. Main Outcome Measure(s): Fractures of any type, and at osteoporotic sites (e.g., hip, spine, or wrist) alone, as assessed by electronic review of inpatient and outpatient diagnoses in the community. Result(s): Compared with controls, there was a significant increase (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.13-1.29) in overall fracture risk among the women with a hysterectomy, but osteoporotic fracture risk was not elevated (HR, 1.09; 95% CI, 0.98 -1.22). Most hysterectomy indications were associated with fractures generally, although these were not often statistically significant. Only operations for a uterine prolapse were associated with osteoporotic fractures (HR, 1.33; 95% CI, 1.01-1.74). Oophorectomy was not an independent predictor of fracture risk (HR, 1.0; 95% CI, 0.98 -1.15). Hysterectomy does not appear to pose much long-term risk for fractures, but the association of fractures with surgery for uterine prolapse deserves further attention. (Fertil Steril 2007
Female pelvic medicine & reconstructive surgery, 2017
Accounting for selection bias, MMC is associated with decreased operative time, non-UTI morbidity... more Accounting for selection bias, MMC is associated with decreased operative time, non-UTI morbidity, and hospital costs to patients compared with sacrocolpopexy in treating posthysterectomy prolapse.
American Journal of Obstetrics and Gynecology, Feb 1, 2018
The purpose of this video is to demonstrate three different closed-techniques insertions of supra... more The purpose of this video is to demonstrate three different closed-techniques insertions of suprapubic catheters (SPC). Short term voiding dysfunction after pelvic surgery is a common occurrence that is managed with bladder drainage via a transurethral catheter (TUC) or suprapubic catheter. The declining use of the SPC has been attributed to its invasive nature through a suprapubic skin incision and the creation of a cystotomy. However, the cystotomy and skin incision are less than 1-cm wide and heal within 24 hours after removal of the catheter. When compared to TUCs, SPCs have been associated with fewer urinary tract infections, less urethral trauma, better patient satisfaction, and greater ease of management. Most early-mid career gynecologic surgeons have less experience with SPCs in their training and are thus less inclined to use it. As pelvic surgeons, we should have the ability to offer this option when indicated because SPC insertion, management, removal, and troubleshooting is not complicated. The goal of this video is to provide guidance for surgeons interested in learning to use SPCs for treating short term voiding dysfunction when indicated. MATERIALS AND METHODS: We will review the advantages and disadvantages of the SPC versus the TUC. Next, we will present 3 teaching videos; 2 split-screen (cystoscopic view/perineal view) followed by a single screen. The 2 split-screen videos will review the components, assembly and insertion of the Rutner balloon SPC and the Mac-Loc SPC respectively. The last video will demonstrate a Lowsley retractor assisted SPC insertion. CONCLUSION: Short term voiding dysfunction is a common occurrence after pelvic surgery. The selection of either a suprapubic or transurethral bladder drainage depends on the specific clinical scenario. The SPC is a useful tool for any pelvic surgeon's virtual toolbox. We hope this video provides some guidance for others to optimize their use of the SPC.
The use of graft tissues to supplement pelvic reconstruction is becoming more common. Many tissue... more The use of graft tissues to supplement pelvic reconstruction is becoming more common. Many tissues are being used including xenografts, allografts and autografts. There are no good data on the disposition of any of these grafts tissues after implantation in the human pelvis. OBJECTIVE: We evaluate the disposition of Pelvicol (porcine dermal graft) 12 months after implantation for rectocele repair. MATERIALS AND METHODS: Patients underwent rectocele repair alone or in combination with other pelvic reconstruction procedures. Pelvicol was used to reconstruct the rectovaginal septum. 12 months following the surgery, 8 patients were asked to participate in a biopsy study at the rectocele repair site. All patients participated on a voluntary basis and received compensation for their participation. A 3mm punch biopsy was taken from the repair site, incorporating full-thickness of the recto-vaginal septum. Care was taken to not injure the rectum. A sample of normal vaginal mucosa and a sample of Pelvicol were also studied for cross-reactivity of the collagen stains. Porcine and human collagen localizations were performed by immunoperoxidase staining using polyclonal rabbit anti-porcine and anti-human Type I/III collagen antibodies on a Vantana Benchmark automatic stainer. Porcine antibody was diluted 15 times and human antibody was diluted 10 times. RESULTS: Both porcine and human collagen were visualized in all 8 biopsies. These collagens were intermixed in the tissue samples. Both positive and negative control tissues stained appropriately with minimal cross reactivity of anti-porcine collagen antibody in normal human tissue or anti-human collagen antibody in the Pelvicol. CONCLUSIONS: This study demonstrates the persistence of Pelvicol 12 months after implantation and the in-growth of human collagen into the dermal matrix.
American Journal of Obstetrics and Gynecology, Mar 1, 2010
The purpose of this study was to compare complications from vaginal hysterectomy with abdominal h... more The purpose of this study was to compare complications from vaginal hysterectomy with abdominal hysterectomy in renal transplant recipients. STUDY DESIGN: Women who underwent renal transplantation then hysterectomy from 1966-2008 at Mayo Clinic, Rochester, MN, were identified. Data were collected about preoperative, intraoperative, and postoperative events. Main outcome measure was loss of allograft function; secondary outcomes included types of complications and treatment methods. RESULTS: Of 58 women with renal transplants, 42 women (72.4%) underwent abdominal hysterectomy. The most common indication for hysterectomy was menorrhagia (n ϭ 20; 34.5%). Overall, 24 women (41.4%) had complications, the most common of which were infection (n ϭ 15) and transfusion (n ϭ 8). Women who underwent abdominal hysterectomy were no more likely to have perioperative complications than were women who underwent vaginal hysterectomy (odds ratio, 1.25; 95% confidence interval, 0.38 -4.08). CONCLUSION: Although patients with renal transplants had perioperative complications, none of these complications led to renal graft loss. Hysterectomy can be considered in these patients when accompanied by diligent postoperative care.
Female pelvic medicine & reconstructive surgery, 2019
The aim of this study was to compare outcomes of vaginal hysterectomy between patients with and w... more The aim of this study was to compare outcomes of vaginal hysterectomy between patients with and without the following perceived contraindications to vaginal surgery: uterine weight greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Methods: Retrospective cohort of benign vaginal hysterectomies between 2009 and 2013 was obtained. Outcomes included uterine debulking, transfusion, intraoperative complications, length of stay, and Accordion grade 2+ postoperative complications. For each outcome, the association between the presence of each contraindication and the outcome was evaluated using univariate and multivariate logistic regression models. Results: Among 692 vaginal hysterectomies, 11% (76/691) had a uterine weight greater than 280 g, 11.3% (78/690) had no vaginal parity, 14.9% (103/690) had a history of cesarean delivery, and 37.7% (248/657) had a body mass index of 30 kg/m 2 or greater; 110 (15.9%) had 2 or more contraindications. Uterine debulking occurred in 146 women (21.1%), and both uterine weight greater 280 g (adjusted odds ratio, 39.2; 95% confidence interval, 18.4-83.5) and prior cesarean delivery (adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7) were significantly associated with an increased likelihood of uterine debulking after adjusting for age, hematologic disease, and preoperative diagnosis. None of the contraindications were significantly associated with need for a blood transfusion, presence of an intraoperative complication, length of stay greater than 2 days, or presence of an Accordion grade 2+ postoperative complication, which occurred in 2.7%, 2.5%, 14.0%, and 6.9% of all women, respectively. Conclusions: Vaginal hysterectomy can be safely performed with favorable outcomes, even in women with a uterus greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Our findings challenge several perceived contraindications to vaginal hysterectomy.
p = 0.002), and sterilizations (p ! 0.001) than the 2003 graduates. The above findings were uncha... more p = 0.002), and sterilizations (p ! 0.001) than the 2003 graduates. The above findings were unchanged when evaluating procedures for which the resident was the primary surgeon. Duty-hour restrictions have not adversely affected the operative experience of obstetrics and gynecology residents. No significant differences in the number of the spontaneous vaginal deliveries, abdominal hysterectomies, or vaginal hysterectomies performed were observed.
Journal of Pelvic Medicine and Surgery, Jul 1, 2005
Background: Congenital abnormalities and malformations are more frequent in the urinary tract tha... more Background: Congenital abnormalities and malformations are more frequent in the urinary tract than in any other system of the body. The present study was conducted to evaluate incidence of congenital anomalies in urogenital tract in infants and children. Subjects and Methods: The present study was conducted on 55 cases age ranged 6 months to 8 years of congenital anomalies of urogenital tract which were admitted in department of Pediatric surgery ward of Kamla Nehru hospital, Bhopal during 1 year period. Type of anamoly was also recorded. In all patients, thorough clinical examination was performed. USG was done in all cases to confirm the cases. Results: Out of 1500 pediatric admissions, 56 (3.6%) had anomalies in urinary tract. In males, maximum lesions were hyposposdias seen in 13 followed by VUR & PUV in 12 patients and phimosis in 6 and 1 case of diphallia was found. In females, maximum lesions were congenital hydronephnosis, pelvic kidney, horse shoe kidney, ectopic ureter and ectopia vesicae seen in 1 patient each. Increased frequency of micturition was seen in 16, urine through ureter opening was seen in 12, dribbling of urine in 15 and suprapubic swelling was observed in 8 cases. USG revealed congenital hydronephnosis in 2, PUJ obstruction in 2, pelvic kidney in 2, ectopia vesicae in 2, ureterocele in 2. Conclusion: Authors found that maximum cases were of Hyposposdias followed by VUR & PUV and phimosis.
Objective: To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorde... more Objective: To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorders with that in control subjects.
We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vagi... more We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vaginal hysterectomy, including tips for troubleshooting difficult cases such as: uterine procidentia, cervical elongation, and multiple prior cesarean sections. Methods Anterior cul-de-sac entry is a critical step in performing a vaginal hysterectomy. In this video, we review our approach to anterior entry in patients with normal anatomy, followed by a discussion of techniques that may be useful in cases with challenging anatomy. To start, we drain the bladder, set up exposure with Deaver retractors, and make a circumferential incision at the cervicovaginal junction. In cases with normal anatomy, using sharp, followed by broad blunt finger dissection, the vesicocervical space is opened, and the peritoneal reflection is identified and sharply entered. If this is not possible, additional techniques such cystoscopic bladder illumination, posterior entry first, securing pedicles with extraperitoneal ties, or additional sharp dissection may be utilized. With all techniques, proper intraperitoneal entry should be verified by the visualization of small bowel or fat. Conclusion This video reviews technical considerations for anterior cul-de-sac entry during vaginal hysterectomy in patients with normal anatomy and provides tips for troubleshooting challenging cases.
American Journal of Obstetrics and Gynecology, Mar 1, 2017
RESULTS: Dichotomous predictor variables for length, height, and width were calculated separately... more RESULTS: Dichotomous predictor variables for length, height, and width were calculated separately based on differential percentile scores and combined with age in a logistic regression analysis. The logistic regression model was statistically significant, c 2 (4) ¼ 299.825, p < 0.000. The model explained 80.5% (Nagelkerke R 2 ) of the variance in procedure type and correctly classified 94.6% of cases. Sensitivity was 85.3%, specificity was 98.1%, positive predictive value was 94.57%, and negative predictive value was 94.55%. This created a predictive weighted index incorporating age with length, height, and width. Age >50 years counts as one point, while length (>11 cm), height (>8 cm), and width (>6.9 cm) each count for 3 points resulting in a potential scale range of 0 to 10 points. An index score of 4 or higher suggests the need for an alternative to vaginal extraction (94.5% of the current sample). Factoring in patient parity or uterine volume to the equation did not statistically influence the predictive power of the model. We have created a simple model for predicting vaginal extraction of specimens during laparoscopic hysterectomy. In the current environment, with morcellation under scrutiny, this may enable clinicians to better anticipate the need for an alternate route of specimen delivery and counsel patients accordingly.
American Journal of Obstetrics and Gynecology, Mar 1, 2017
retention or obstructive voiding symptoms, complex urinary incontinence symptoms, complicated low... more retention or obstructive voiding symptoms, complex urinary incontinence symptoms, complicated lower urinary tract surgical history or conditions increasing the risk for poor bladder compliance or vesicoureteral reflux. An example of a normal video urodynamic study is described to demonstrate important techniques and to show the five points at which images are generally obtained. Examples of interesting study findings are discussed. Findings include bladder diverticula, detrusor overactive with leakage, poor bladder compliance, vesicoureteral reflux, stress incontinence, detrusor external sphincter dyssynergia, open bladder neck, and urethral diverticulum. CONCLUSION: Video urodynamics has several important advantages over conventional urodynamics for the evaluation of patients with lower urinary tract symptoms. It gives the clinician simultaneous functional and anatomic views of the urinary tract. While this can be of great benefit for specific patient presentations, the advantages do not come without potential risks. Financial costs and risk of radiation exposure must be weighed against the benefit. Nevertheless, in complicated patients, as illustrated here, video urodynamics may be invaluable in evaluating complex lower urinary tract dysfunction.
Journal of Minimally Invasive Gynecology, Mar 1, 2015
Objective: To describe and demonstrate an alternative surgical laparoscopic approach to removing ... more Objective: To describe and demonstrate an alternative surgical laparoscopic approach to removing polypropylene mesh embedded and perforating the bladder by way of robotic assistance. Description: Mid-urethral slings (MUS) are currently the most common surgical procedure for the treatment of female stress incontinence. Although retropubic MUS complications are uncommon, they can occur. Of these, intraoperative bladder perforation is the most common with an incidence of 3.5-6.6%. When diagnosed, polypropylene mesh compromising the integrity of the bladder must be completely removed. Methods: Following delayed recognition of a through-and-through perforation of the bladder by passage of a retropubic midurethral sling, we elected to proceed with a robotic-assisted laparoscopic retropubic dissection and transvesical resection of the embedded sling with intraoperative cystoscopy and ureteral stent placement. Results: Patient underwent a successful robotic-assisted laparoscopic resection of an embedded retropubic MUS. The operation was uncomplicated. Blood loss was 50 ml and the total operative time was 2 hours and 40 minutes. The patient tolerated the procedure well and was discharged home the following day with an indwelling Foley catheter. Her perioperative course was uncomplicated and she went on to have complete resolution of her presenting symptoms and follow-up office cystoscopy revealed a normal appearing bladder. Conclusion: Given the increasing number of robotic-assisted laparoscopic procedures and expertise with robotic surgery in the U.S., a robotic-assisted laparoscopic procedure may be an attractive alternative to managing complications related to perforation or erosion by synthetic mesh.
Pelvic organ prolapse (POP) is a prevalent condition that can have a significant impact on a pati... more Pelvic organ prolapse (POP) is a prevalent condition that can have a significant impact on a patient's quality of life. Treatment is indicated for patients who are symptomatic or those that have associated bladder, bowel, or sexual dysfunction. The decision to proceed with conservative management or surgery is based on multiple factors, including symptoms, treatment goals, risk and benefits of intervention, sexual functioning, and medical comorbidities. Overall, the lifetime risk of a woman undergoing surgery for POP is 13%. Transvaginal surgical approaches include reconstructive and obliterative procedures. Native-tissue repair has been demonstrated to be a safe and effective treatment option for addressing POP and is an important skill set for gynecologic surgeons. This review discusses the different techniques available for transvaginal POP repair. ( J GYNECOL SURG 39:12
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