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BACKGROUND: Women with Mayer-Rokitansky-Kuster-Hauser syndrome have congenital absence of the uterus and upper two-thirds of the vagina, which is frequently accompanied by skeletal and renal anomalies. Mechanical dilation or surgical creation of a vagina allows for function but does not provide endopelvic fascial support of the vagina. Vaginal prolapse may occur. CASE: A 32-year-old woman presented with pelvic kidneys and a 5-year history of prolapse of her mechanically created neovagina. She underwent a sacrospinous ligament suspension with a cadaveric fascia lata bridge. The apex of the neovagina was 5 cm above the hymen 30 months postoperatively. CONCLUSION: An allograft colpopexy to the sacrospinous ligament is an effective method of surgical treatment of women with a prolapsed shortened vagina and an inaccessible presacral space. [ABSTRACT FROM AUTHOR]

Objective: To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings., Methods: Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care., Results: One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01)., Conclusion: This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objectives: This study aimed to identify the characteristics associated with overactive bladder (OAB) symptoms perioperatively in patients undergoing pelvic organ prolapse (POP) surgery with and without slings and to determine the rate of OAB symptom resolution postoperatively., Methods: This retrospective, single-institution study involved women undergoing prolapse surgery with and without concomitant midurethral sling from 2011 to 2016. A validated questionnaire was used to determine OAB symptoms preoperatively and postoperatively. The primary outcome was rate of resolution in OAB symptoms after POP surgery with and without midurethral sling. Baseline characteristics and surgery type were presented, and univariate and multivariate logistic regression models were applied to evaluate characteristics associated with OAB symptoms at the first postoperative visit., Results: The analysis included 203 patients. Among those with baseline OAB symptoms, 103 (61%) had symptom resolution, whereas 66 (39.1%) reported persistent symptoms. Among 34 patients without baseline OAB symptoms, 6% developed de novo symptoms. Older age was found to be a significant risk factor for persistence of symptoms postoperatively both on univariate (odds ratio, 0.97; 95% confidence interval, 0.94-1; P = 0.038) and multivariate logistic regression (odds ratio, 0.96, 95% confidence interval, 0.92-1; P = 0.049). The rate of medication discontinuation postoperatively was 25%., Conclusions: Approximately 61% of patients undergoing POP surgery had resolution of OAB symptoms postoperatively whether or not an incontinence procedure was performed. Older age was significantly related to persistent OAB symptoms in both univariate (P = 0.038) and multivariate (P = 0.049) models. The rate of de novo OAB symptoms was 6%., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: : To test the hypothesis that body mass index (BMI) is a factor associated with passing a voiding trial after midurethral sling procedures for stress urinary incontinence (SUI)., Study Design: : The medical records of 136 consecutive patients who underwent placement of either tension-free vaginal tape (TVT) or transobturator tape (TOT) for SUI during a 1-year period (September 1, 2007 to August 31, 2008) were retrospectively reviewed. Variables assessed were BMI, age, and passing or failing a postoperative urinary voiding trial. Patients with concomitant pelvic organ prolapse surgeries were not included in this analysis., Results: : Sixty-seven patients underwent TVT, whereas 69 had TOT procedures. In the TVT group, 30 patients (42%) were unable to void immediately postoperatively compared with 11 patients (16%) in the TOT group (P = 0.0003). The mean (SD) age and BMI of patients who failed or passed voiding trials was 58.6 (12.0) years and 28.0 (4.9) kg/m or 53.5 (12.3) years and 29.8 (5.7) kg/m, respectively. Of 38 patients who did not pass a voiding trial on the day of the procedure, 31 (82%) passed on postoperative day 1, and all patients had passed a voiding trial by postoperative day 11. The mean (SD) BMI for 7 patients who did not pass voiding trial by postoperative day 1 was 28.3 (5.2) kg/m., Conclusions: : Women with higher BMIs were more likely to pass voiding trials after midurethral sling procedures. Patients who had TOT placement had greater success passing a postprocedure voiding trial than did patients who had TVT placement.

A 66-year-old para III with a 20-year history of stress urinary incontinence underwent placement of tension-free vaginal tape. Intraoperative arterial bleeding occurred. An expanding hematoma was palpated postoperatively. Interventional radiology performed a pelvic arteriogram with selective bilateral internal iliac arteriograms, a supraselective anterior division and obturator arteriogram, a left external iliac arteriogram, coil embolization of a branch of the left obturator artery, and gel foam embolization of the anterior division of the left internal iliac artery.

Objective: To describe the proximity of the major vessels in the retropubic space and anterior abdominal wall to the tension-free vaginal tape needle., Methods: Tension-free vaginal tape needles were inserted bilaterally in ten cadavers. Dissection of the superficial epigastric, inferior epigastric, external iliac, and obturator vessels was performed. Measurements from the lateral aspect of the needle to the medial edge of the vessels were recorded. In an additional cadaver, three planes were created by placing a string from the midlabia to the shoulder, mid-biceps brachii muscle, and 6 cm lateral to the mid-biceps brachii muscle of the cadaver's extended, ipsilateral arm. An operator, blinded to the retropubic space anatomy, passed the needle in these planes bilaterally. The distances from the needle to the external iliac and obturator vessels were measured., Results: All vessels measured were lateral to the tension-free vaginal tape needle. The mean distance from the tension-free vaginal tape needle to the obturator vessels was the closest: 3.2 cm (range 1.6-4.3 cm). The mean distance from the tension-free vaginal tape needle to the superficial epigastric vessels was 3.9 cm (range 0.9-6.7); to the inferior epigastric vessels, 3.9 cm (range 1.9-6.6 cm); and to the external iliac vessels, 4.9 cm (range 2.9-6.2 cm). When the needle was directed 6 cm lateral to the mid-biceps brachii muscle, the external iliac vein was punctured., Conclusion: The major vessels in the retropubic space and anterior abdominal wall lie 0.9-6.7 cm lateral to the tension-free vaginal tape needles. If the tension-free vaginal tape needle is laterally aimed or rotated, major vascular injury can occur.

Background: Tension-free vaginal tape procedure is a popular surgical treatment of genuine stress urinary incontinence., Cases: Two cases of retropubic hematoma after tension-free vaginal tape procedure are reported. One woman with an 8 x 10 cm hematoma localized to the retropubic space required transfusion of two units of packed red blood cells for symptomatic relief. Neither case required reoperation, and both patients' hematomas resolved over 6 months without treatment. Both patients were continent 9-12 months after surgery., Conclusion: Although the tension-free vaginal tape procedure is a minimally invasive operation for stress urinary incontinence and appears to be effective, significant vascular complications can result.