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Abdominal pelvic organ prolapse repair is efficacious for uterovaginal and apical prolapse. We describe the safety and efficacy of robotic prolapse repair in a large teaching institution., Methods: Consecutive robotic-assisted prolapse repairs at a single institution between 2006 and 2014 were retrospectively reviewed for patient characteristics, operative information, and outcomes., Results: A total of 196 women (mean age, 61 ± 9 years) underwent robotic prolapse repair (189 sacrocolpopexy, 6 sacrohysteropexy, 1 enterocele repair). Concomitant procedures included hysterectomy (88), midurethral sling (84), and/or Burch colposuspension (7). Mean odds ratio time was 242 ± 69.9 minutes, and median length of stay was 1 day. Intraoperative complications were as follows: cystotomy (4), vaginotomy (4), conversion to open (2), bowel injury/aborted (1), adhesions/aborted (1), and ureteral injury (1). Women with complications had greater blood loss than those without complications (P = 0.0015). Immediate (<30 days) postoperative complications were rare: port-site hernia (2), discitis (1), ileus (1), and ulnar neuropraxia (3). At median follow-up of 9 months (range, 0-85 months), 14 women had recurrent grade 3 prolapse, and 4 had grade 2 apical prolapse. Nine of 14 women had additional prolapse repair at a mean of 9.5 ± 6.3 months. Vaginal mesh exposure was detected in 12 (6.3%) of 192 women. There were 6 procedures for mesh exposure and 2 procedures for exposed sutures. One mesh erosion into the bladder required open excision., Conclusions: In this large series of robotic prolapse repair, complications are infrequent. Short-term apical outcomes are excellent. Few women required additional compartment repairs within 1 year with 6% rate of mesh exposure.

Objectives: Injectable urethral bulking agents are commonly used to manage stress urinary incontinence. Urologic or other symptoms may prompt pelvic imaging at a later date, when bulking agents may be visualized and incorrectly interpreted. Our goal was to evaluate the incidence of misdiagnosis and which pathologies were the most common misinterpretations and their frequency., Methods: All records were reviewed for patients who underwent periurethral injection for stress urinary incontinence for pelvic imaging after treatment from 2005 to 2015. Radiological reports were reviewed for any description potentially related to injection therapy, and descriptive statistics performed., Results: A total of 528 patients underwent injection of a urethral bulking agent. Of these, 79 patients (15%) had a total of 111 additional abdominal or pelvic imaging studies performed with abnormal periurethral findings mentioned. Thirty-nine (35%) of 111 studies were correctly interpreted as urethral bulking agents, and in 72 (65%) of 111 studies, the urethral bulking agents were not correctly identified. The most common misdiagnoses were bladder calcification (26; 23%), urethral diverticulum with stone (12; 11%), periurethral calcification (9; 8%), unknown pelvic density (8; 7%), and mass suspicious for malignancy (6; 5%)., Conclusions: Urethral bulking agents commonly were not mentioned on subsequent imaging but, when commented on, were misinterpreted 65% of the time including worrisome pathologies (diverticulum with stone, unknown mass, and malignancy), requiring subsequent evaluation and potentially procedural/surgical management. It is critical for the ordering clinician to inform the radiologist of this history and for radiologists to consider bulking agents in the differential diagnosis of radiographic findings in this location.

Introduction: Women with pelvic floor dysfunction can have tender areas on vaginal examination, which can be treated with trigger-point injections. There are no publications to evaluate the accuracy of pelvic floor muscle injections., Methods: Trigger-point injections were performed on 2 fresh cadaveric pelvises using a curved nasal cannula guide and 7-in spinal needle. This was performed using our standard template of 2 sets of injections at the 1-, 3-, and 5-o'clock positions distally and proximally. The first pelvis was dissected to examine dye penetration. Based on these results, we modified our technique and repeated the injections on the second cadaver. We dissected the second pelvis and compared our findings., Results: The 1-o'clock proximal and distal injections stained the obturator internus and externus near the insertion at the ischiopubic ramus. The 3-o'clock injections stained the midbody of the pubococcygeus and puborectalis. The distal 5-o'clock position was too deep and stained the fat of the ischiorectal space. The proximal 5-o'clock injection stained the area of the pudendal nerve. Our goal at the distal 5-o'clock position was to infuse the iliococcygeus muscle, so we shortened the needle depth from 2 to 1 cm beyond the cannula tip. In our second dissection, the distal 5-o'clock injection again stained only the fat of the ischiorectal space., Conclusions: This is the first study to characterize the distribution of pelvic floor muscle injections in a cadaver model and confirms the ability to deliver medications effectively to the pelvic floor muscles.

Objectives: This study aimed to assess the efficacy, efficiency, and costs of 2 methods of trial of void (TOV) after midurethral sling (MUS) placement., Methods: A retrospective chart review was performed on women who underwent outpatient MUS between January 2013 and April 2014 by 3 urologists. Patients were excluded if they had a concomitant prolapse repair, hysterectomy, bladder/urethral injury, or any procedure that may prolong recovery room (RR) stay. Trial of void was performed by either (1) bladder instillation, catheter removal in the operating room (OR) fill with attempted void in RR, or (2) bladder instillation and catheter removal with immediate attempted void in the RR fill. Intraoperative, postoperative, and cost data were analyzed., Results: Ninety-one of 183 women (mean age, 55.9 ± 12 years; mean body mass index, 28.8 ± 5.8 kg/m) met inclusion criteria. Eighty-three had a transobturator sling. Forty-nine (54%) had an OR fill and 42 (46%) had an RR fill; age and body mass index were similar between groups. The OR fill group had shorter median operative time (15 vs 22 minutes; P = 0.003) and median RR time (138 vs 161, P = 0.033). The OR fill and RR fill groups did not differ in TOV failure rate (3/49 vs 6/42; P = 0.29), overall mean LOS (4.96 vs 5.51 hours; P = 0.055), and median RR costs ($627 vs $678; P = 0.065). No patient had urinary retention after successful TOV., Conclusions: After MUS placement, both OR fill and RR fill TOV methods are effective and efficient with similar TOV failure rates.