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The objective was to demonstrate the build and use of a low-cost, moderate-fidelity simulation model for LeFort colpocleisis. We a present a video demonstrating the creation of a LeFort colpocleisis model, the mounting of this model to a pre-existing vaginal hysterectomy simulator (SimVaHT), and the use of the model to teach the steps of the LeFort colpocleisis procedure. This LeFort colpocleisis model is easy to make, from readily available materials, and is inexpensive. It can help trainees to enhance their intraoperative learning.

It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly. The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications. A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), “other race” (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications. ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

This video demonstrates surgical repair of a vesicouterine fistula via a robotic, uterine-sparing approach. In this video, we present a vesicouterine fistula, which occurred after cesarean delivery. The patient presented with cyclical hematuria 4 years following delivery. She underwent uterine-conserving robotic repair via excision of the fistula tract through an intentional cystotomy. The uterus and bladder were closed in multiple layers. The patient tolerated the procedure well, and CT cystogram 6 weeks following surgery demonstrated no concern for defect or recurrent fistulization. The patient was asymptomatic 9 months following her procedure. Repair of a vesicouterine fistula may be safely completed via a minimally invasive approach without need for routine hysterectomy.

OBJECTIVES The purpose of this study was to explore the utility of an injectable purified exosome product derived from human apheresis blood to (1) augment surgical closure of vaginal mesh exposures, and (2) serve as a stand-alone therapy for vaginal mesh exposure. METHODS Sixteen polypropylene meshes (1×1-3×3 cm) were implanted in the vaginas of 7 Yorkshire-crossed pigs by urogynecologic surgeons (day 0). On day 7, group 1 underwent surgical intervention via vaginal tissue suture reclosure with (n=2 pigs, n=4 meshes) or without (n=2 pigs, n=4 meshes) exosome injection; group 2 underwent medical intervention with an exosome injection (n=3, n=8 meshes). One animal in group 2 was given oral 2'-deoxy-5-ethynyluridine to track cellular regeneration. Euthansia occurred at 5 weeks. RESULTS Mesh exposures treated with surgical closure alone experienced reexposure of the mesh. Exosome treatment with or without surgical closure resulted in partial to full mesh exposure resolution up to 3×3 cm. Exosome-treated tissues had significantly thicker regenerated epithelial tissue (208 μm exosomes-only and 217 μm surgery+exosomes, versus 80 μm for surgery-only; P < 0.05); evaluation of 2'-deoxy-5-ethynyluridine confirmed de novo regeneration throughout the epithelium and underlying tissues. Capillary density was significantly higher in the surgery+exosomes group (P = 0.03). Surgery-only tissues had a higher inflammatory and fibrosis response as compared with exosome-treated tissues. CONCLUSIONS In this pilot study, exosome treatment augmented healing in the setting of vaginal mesh exposure, reducing the incidence of mesh reexposure after suture closure and decreasing the area of mesh exposure through de novo tissue regeneration after exosome injection only. Further study of varied local tissue conditions and mesh configurations is warranted.

OBJECTIVE To compare the perioperative outcomes of transvaginal/perineal and abdominal approaches to rectovaginal fistula (RVF) repair using a national multicenter cohort. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify women undergoing RVF repair from 2005 to 2016. Emergent cases and those with concomitant bowel diversion were excluded. Baseline patient demographics, procedure characteristics, 30-day postoperative complications, return to the operating room, and readmission were evaluated. Baseline characteristics were compared across surgical approach. Multivariable logistic regression models identified preoperative characteristics independently associated with postoperative complications. RESULTS A total of 2288 women underwent RVF repair: 1560 (68.2%) via transvaginal/perineal approach and 728 (31.8%) via abdominal approach. Patients undergoing transvaginal/perineal repair were significantly younger (median age, 46 years vs 63 years), with lower American Society for Anesthesiologist (ASA) scores, and less frequency of diabetes mellitus, dyspnea, severe chronic obstructive pulmonary disease, hypertension, disseminated cancer, and bleeding disorders (all P < 0.01). Those undergoing abdominal repair had higher rates of major complications (25.8% vs 8.7%), minor complications (13.5% vs 6.3%), and readmission (13.2% vs 7.8%). On multivariable analyses, ASA Class 3/4, disseminated cancer, and hematocrit

We present a video describing the technical considerations for performing a LeFort colpocleisis. A 79-year-old woman presented with a symptomatic vaginal bulge. She was not sexually active, and had no desire to maintain the vaginal canal. Her history was significant for aortic valve replacement, chronic anticoagulation, and a cardiac pacemaker. She had uterine procidentia, with occult stress urinary incontinence. After discussing options, she elected to undergo LeFort colpocleisis. Following sharp endometrial curettage, hydro-dissection was performed with lidocaine and epinephrine. Rectangular patches of vaginal epithelium were excised anteriorly and posteriorly, and the proximal margins were re-approximated, inverting the cervix. Following this, the lateral margins were re-approximated to create lateral channels. The anterior and posterior rectangles were then plicated, reducing the prolapse. The vaginal incision was closed transversely. A retropubic, synthetic, mid-urethral sling was placed, and an aggressive posterior colpoperineorrhaphy was performed. Her postoperative course was uncomplicated. At her 6-week follow-up she had no recurrent prolapse, denied stress incontinence, and was voiding without difficulty. Important tips for LeFort colpocleisis include ruling out underlying malignancy, using lidocaine with epinephrine for hydrodissection, creating adequate lateral channels, closure in multiple layers with excellent hemostasis, and an aggressive posterior repair.

OBJECTIVE The aim of the study was to compare vaginal wound healing after exosome injection in a porcine mesh exposure model with (1) single versus multiple dose regimens and (2) acute versus subacute exposure. METHODS Six 80-kg Yorkshire-crossed swine each had 2 polypropylene meshes implanted to create the vaginal mesh exposure model. Animals were divided into 3 groups based on number and timing of exosome injection: (1) single purified exosome product (PEP) injection (acute-single), (2) weekly PEP injections (acute-weekly, 4 total injections), and (3) delayed single injection (subacute-single). Acute and subacute injections occurred 1 and 8 weeks after mesh implantation, respectively. EdU, a thymidine analog, was given twice weekly after the first injection to track tissue regeneration. Euthanasia and tissue analysis occurred 4 weeks after the first injection. ImageJ was used to quantify epithelial thickness, cellular proliferation, and capillary density. Statistical analysis was performed using analysis of variance and post hoc Tukey test. RESULTS Acute-single PEP injection tissues mirrored pilot study results, validating replication of protocol. Within the acute groups, weekly dosing resulted in 1.5× higher epithelial thickness (nonsignificant), 1.8× higher epithelial proliferation (P < 0.05), and 1.5× higher regenerated capillary density (P < 0.05) compared with single injection. Regarding chronicity of the exposure, the subacute group showed 1.7× higher epithelial proliferation (nonsignificant) and similar capillary density and epithelial thickness as compared with the acute group. CONCLUSIONS Exosome redosing resulted in significantly greater epithelial proliferation with significantly higher regenerated capillary density, leading to a trend toward thicker epithelium. Subacute exposure exhibited similar regeneration to acute exposure despite a delayed injection timeline. These results contribute to a growing body of preclinical research demonstrating utility of exosomes in pelvic floor disorders.

Growing literature details the critical importance of the microbiome in the modulation of human health and disease including both the gastrointestinal and genitourinary systems. Rectovaginal fistulae (RVF) are notoriously difficult to manage, many requiring multiple attempts at repair before correction is achieved. RVF involves two distinct microbiome communities whose characteristics and potential interplay have not been previously characterized and may influence surgical success. In this pilot study, rectal and vaginal samples were collected from 14 patients with RVF. Samples were collected preoperatively, immediately following surgery, 6–8 weeks postoperatively and at the time of any fistula recurrence. Amplification of the 16S rDNA V3-V5 gene region was done to identify microbiota. Data were summarized using both α-diversity to describe species richness and evenness and β-diversity to characterize the shared variation between communities. Differential abundance analysis was performed to identify microbial taxa associated with recurrence. The rectal and vaginal microbiome in patients undergoing successful fistula repair was different than in those with recurrence (β-diversity, p = 0.005 and 0.018, respectively) and was characterized by higher species diversity (α-diversity, p = 0.07 and p = 0.006, respectively). Thirty-one taxa were enriched in patients undergoing successful repair to include Bacteroidetes, Alistipes and Rikenellaceae as well as Firmicutes, Subdoligranulum, Ruminococcaceae UCG-010 and NK4A214 group. Microbiome characteristics associated with fistula recurrence have been identified. The association of higher vaginal diversity with a favorable outcome has not been previously described. Expansion of this pilot project is needed to confirm findings. Taxa associated with successful repair could be targeted for subsequent therapeutic intervention.

We compared the degree of pelvic floor symptom improvement between pessary use and prolapse surgery.Pessary-naïve women who elected prolapse surgery were enrolled and used a pessary preoperatively (for ≥7 days and ≤30 days). Pelvic floor symptoms were assessed at baseline, after pessary use, and at 3 months postoperatively. The primary outcome was concordance in the degree of symptoms improvement between pessary use and surgery, as assessed by Patient Global Impression of Improvement (PGI-I). Secondary outcomes were related to prolapse specific symptoms on validated questionnaires (POPDI-6, PFIQ-7). The McNemar test was used for comparisons of discordant pairs for comparisons of the PGI-I ratings after pessary use and surgery.Sixty-one participants were enrolled (March 2016 through April 2019) and 58 patients used a pessary. Mean±standard deviation age was 60.7±10.7 years; 24.1% had prior hysterectomy, and 13.8% had prior prolapse surgery. While both treatments demonstrated symptomatic improvement, concordance in the degree of overall improvement on the PGI-I score was poor (n=40); responses significantly favored more improvement postoperatively (p0.001). Pessary use and surgery were associated with significant improvements in prolapse symptoms from baseline on POPDI-6 (both p0.001) and POPIQ-7 (pessary, p=0.002; surgery, p0.001). The degree of improvement was larger postoperatively compared to post-pessary use on POPDI-6 (p0.001) and PFIQ-7 (p=0.004).Both pessary use and surgery significantly improved pelvic floor symptoms from baseline. However, concordance in degrees of improvement between these treatments was poor, with more favorable outcomes after surgery for prolapse symptoms.

We evaluated the perioperative morbidity of open abdominal sacrocolpopexy and minimally invasive sacrocolpopexy using data on a contemporary nationwide cohort.We used the ACS (American College of Surgeons) NSQIP® (National Surgical Quality Improvement Program) database to identify women who underwent abdominal or minimally invasive sacrocolpopexy from 2010 to 2016. Associations of surgical approach with 30-day complications, blood transfusion, prolonged hospitalization and reoperation were evaluated by logistic regression. Hospital readmission within 30 days was calculated by the person-years method and Cox proportional hazard models.A total of 4,362 women underwent sacrocolpopexy, including abdominal sacrocolpopexy in 1,179 (27%) and minimally invasive sacrocolpopexy in 3,183 (73%). The proportion of minimally invasive sacrocolpopexy increased during the study period from 70% in 2010 to 82% in 2016. Baseline characteristics were similar between the treatment groups aside from a higher rate of chronic obstructive pulmonary disease (p = 0.03) and higher preoperative albumin (p 0.0001) among abdominal sacrocolpopexy cases. Compared to abdominal sacrocolpopexy, minimally invasive sacrocolpopexy was associated with lower rates of 30-day complications (p = 0.001), deep vein thrombosis/pulmonary embolism (p = 0.02), surgical site infections (p0.0001), shorter hospitalization (p 0.0001) and fewer blood transfusions (p = 0.01). Minimally invasive sacrocolpopexy was also associated with a lower 30 person-days readmission rate (2% vs 2.7%, p ≤0.0001) and 30-day reoperation rate (1.1% vs 1.4%, p0.0001). On multivariable analysis minimally invasive sacrocolpopexy was independently associated with a reduced risk of 30-day complications (OR 0.46, 95% CI 0.28, 0.76, p = 0.002), blood transfusion (OR 0.33, 95% CI 0.15, 0.74, p = 0.007), prolonged hospitalization (OR 0.16, 95% CI 0.12, 0.23, p0.001) and readmission (HR 0.62, 95% CI 0.41, 0.96, p = 0.03).Minimally invasive sacrocolpopexy was associated with reduced rates of 30-day complications, blood transfusion, prolonged hospitalization and hospital readmission compared to abdominal sacrocolpopexy.

We aimed to determine the rate of readmission and reoperation for patients undergoing midurethral sling (MUS) placement for stress urinary incontinence (SUI). The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify all isolated MUS placed from 2012 through 2015 using the Current Procedural Terminology 4 (CPT-4) code for MUS with or without cystoscopy (57,288 ± 52,000). The cohort was then reviewed for unplanned, related readmissions and reoperations within 30 days of MUS placement. Isolated MUS was placed in 9910 patients. Fifty-eight (0.59%) patients were readmitted and 81 (0.82%) had reoperation. The most common indications for readmission were related to the urinary tract, i.e., urinary retention (27.6%), non-surgical-site-related infection (15.5%), and medical related issues (15.5%) The most common indications for reoperation were urinary tract (60.5%), gastrointestinal (7.4%), and gynecologic, i.e., examination under anesthesia (6.2%). Body mass index (BMI) was less (p = 0.001), and operative time (p = 0.014) and length of stay (LOS) (p = 0.001) longer in patients who were readmitted. Those who underwent reoperation had longer LOS than those who did not have reoperation (p

Objective To evaluate 1- and 2-year urinary continence rates after Burch retropubic urethropexy compared with a retropubic midurethral sling for women with urinary incontinence undergoing sacrocolpopexy. Methods We conducted a planned secondary analysis of a multicenter, randomized, single-blind trial comparing Burch with a sling that enrolled participants from June 2009 to August 2013. Objective outcome measures of continence were assessed at 1- and 2-year follow-up through office visits and validated questionnaires. Overall continence was defined as a negative stress test, no retreatment for stress incontinence, and no self-reported urinary incontinence (International Consultation on Incontinence Questionnaire, Short Form, score, 0). Stress-specific continence was defined as fulfillment of the first two criteria and no self-reported stress-related incontinence. Primary outcomes were assessed with intention-to-treat and within-protocol analyses. Comparisons between groups were evaluated using χ or Fisher exact test. Results The two groups were similar in all measured baseline features. Outcome assessments at 2 years were available for 48 of 57 patients (84%) in the sling group and 45 of 56 patients (80%) in the Burch group. With intention-to-treat analysis, the sling group had significantly higher rates of overall continence than the Burch group (49% [28/57] vs 29% [16/56]; 95% CI for absolute risk difference 3.0-38.1; P=.03) at 1- but not 2-year follow-up (47% [27/57] vs 32% [18/56]; 95% CI for absolute risk difference -2.6 to 33.1; P=.10). The sling group had significantly higher rates of stress-specific continence than the Burch group at 1-year (70% [40/57] vs 46% [26/56]; 95% CI for absolute risk difference 6.1-41.4; P=.01) and 2-year (70% [40/57] vs 45% [25/56]; 95% CI for absolute risk difference 7.9-43.2; P=.006) follow-up. No difference was detected in prolapse recurrence, voiding dysfunction, antimuscarinic medication use, urgency incontinence, or patient satisfaction. Conclusion Among women with baseline urinary incontinence undergoing sacrocolpopexy, the retropubic midurethral sling resulted in higher stress-specific continence rates than Burch retropubic urethropexy at 1- and 2-year follow-up.

The objective of this video is to demonstrate a variety of available techniques that can be used in the management of acute presacral bleeding. In this video, we demonstrate different methods for the management of presacral bleeding utilizing a fresh frozen cadaver. Presacral bleeding is a potentially catastrophic complication that can be encountered during pelvic surgery, particularly sacrocolpopexy. Various techniques exist to achieve hemostasis in the event of uncontrolled bleeding. This video demonstrates some of the available methods that may be employed in the management of presacral bleeding. The methods demonstrated in this video include direct pressure, pelvic packing, gelatin matrix, bone wax, thumb tack, surgical clip, suture, oxidized regenerated cellulose, omental flap, electrocautery, muscle fragment welding, gelatin matrix combined with thrombin, and microporous polysaccharide spheres. Familiarity with these techniques and product availability will aid in the management of acute presacral bleeding.

The objective of this video is to demonstrate a technique for robot-assisted vesicovaginal fistula (VVF) repair utilizing a mini cystotomy with a transvesical approach. A 53-year-old female developed a VVF after she underwent an abdominal hysterectomy for uterine fibroids at an outside facility. She was referred to us following two failed VVF repairs (one vaginal, one abdominal with bladder bivalving and omental flap). After discussing options, she underwent a robotic VVF repair via a transvesical approach. Following port placement, the space of Retzius was mobilized. An intentional cystotomy was made and the camera and working arms advanced into the bladder. The fistula was identified and circumferentially mobilized. The fistula was closed in three layers using absorbable sutures, and care was taken to avoid the ureters. The patient’s postoperative recovery was uncomplicated. Follow-up imaging was performed via cystogram at 4 weeks and showed resolution of the fistula. A robot-assisted transvesical approach using a mini cystotomy to VVF repair is a useful technique especially when previous surgical planes have been used in prior repairs and failed. It maintains a minimally invasive approach and may avoid complications associated with an open abdominal approach.

The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of prolapse recurrence. The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan–Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence. Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p

Understanding demographic and opioid utilization patterns of preoperative opioid users compared with opioid-naive patients undergoing surgical treatment for pelvic organ prolapse (POP) better informs opioid prescribing. A cohort of preoperative opioid users undergoing surgery for POP from 1 January 2012 through 30 May 2017 was identified. Electronic medical records were utilized to obtain pain scores and prescription data. The cohort was organized by surgical approach, number of concomitant procedures, and patient age. These factors were then matched to pain scores, opioid quantity prescribed at discharge, and subsequent refills. Pain scores and opioid use were evaluated for correlation. Results were then compared with similar data previously published for opioid-naive patients undergoing surgical treatment of POP. Preoperative opioid users were younger (55.5 [14.7] vs 59.5 [12.7]; p = 0.002), of higher body mass index (BMI; 29.2 [5.4] vs 28.6 [10.3]; p = 0.04), and less likely Caucasian (90.3% vs 95.9%; p = 0.002) than opioid-naive patients. After matching for these differences, opioid users reported higher pain scores (3.5 [2.2] vs 2.6 [1.8]; p =

The objective of this study was to evaluate perioperative complications in women who underwent minimally invasive sacrocolpopexy (MISC) versus mesh-augmented vaginal repair (vaginal mesh) for pelvic organ prolapse.We identified patients undergoing MISC and vaginal mesh via Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2016. Those undergoing concomitant hysterectomy were excluded. Univariate analyses were performed to compare baseline characteristics and 30-day complications. Multivariable logistic regression models were constructed to assess the association between surgical approach and complications, prolonged hospitalization, reoperation, and blood transfusion. A multivariable Cox proportional hazard model was used to evaluate hospital readmission.A total of 5722 patients were identified (2573 MISC [45%], 3149 vaginal mesh [55%]). Those undergoing MISC repairs had a significantly lower rate of urinary tract infection (3.1 vs 4.2%; P = 0.03) and blood transfusion (0.5 vs 1.4%; P0.001). There was no difference in reoperation rate (1.3 vs 1.6%; P = 0.35). Multivariable analysis showed no significant association of MISC with overall (odds ratio [OR], 0.91; P = 0.44), major (OR, 1.30; P = 0.31), or minor complication (OR, 0.85; P = 0.26). There were lower odds of receiving a blood transfusion (OR, 0.44; P = 0.02) and higher odds of prolonged hospitalization (2 days; OR, 1.47; P = 0.003) for the MISC group. There was no difference in reoperation (OR, 0.79; P = 0.38) or hospital readmissions (hazard ratio, 1.25, P = 0.32).Minimally invasive sacrocolpopexy was associated with a lower rate of blood transfusion than transvaginal mesh placement. There was no significant difference in 30-day complication rates, reoperation, or readmission between these prolapse procedures when performed without concomitant hysterectomy.

OBJECTIVE The aim of this study was to compare the perioperative morbidity of minimally invasive sacrocolpopexy (MISC) and nonmesh apical vaginal surgeries for repair of vaginal vault prolapse using data from a contemporary nationwide cohort. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify women who underwent apical prolapse surgery via vaginal approach or MISC from 2010 to 2016. Those undergoing concomitant hysterectomy or transvaginal mesh placement were excluded. Associations of surgical approach with 30-day complications, prolonged hospitalization, and reoperation were evaluated using logistic regression. Readmission within 30 days was calculated using the person-years method and Cox proportional hazards models. RESULTS Overall, 6390 women underwent surgery, including 3852 (60%) via vaginal approach and 2538 (40%) via MISC. Patients undergoing MISC were younger (P < 0.0001) and less likely to have hypertension (P = 0.04) or chronic obstructive pulmonary disease (P = 0.008), with lower American Society of Anesthesiologists scores (P < 0.0001) and higher preoperative hematocrit (P = 0.009). The MISC cohort had a lower unadjusted rates of minor complications (3.9% vs 5.6%; P = 0.004), urinary tract infection (3.3% vs 4.8%; P = 0.004), and prolonged hospitalization (5.2% vs 7.9%; P < 0.0001), with a higher rate of nephrologic (P = 0.01) complications. On multivariable analysis, there were no significant associations of MISC with the risk of 30-day complications (odds ratio [OR], 1.51; 95% confidence interval [CI], 0.92-2.51; P = 0.11), prolonged hospitalization (OR, 0.96; 95% CI, 0.76-1.21; P = 0.72), readmission (HR 1.03; 95% CI, 0.71-1.49;P = 0.88), or reoperation (OR, 0.95; 95% CI, 0.57-1.60; P = 0.86). CONCLUSIONS Minimally invasive sacrocolpopexy is associated with similar rates of 30-day complications, prolonged hospitalization, readmission, and reoperation compared with nonmesh vaginal surgeries for apical prolapse.

The objective was to discuss the importance of apical suspension following vaginal hysterectomy and demonstrate a surgical model to aide in educating learners on a variety of apical suspension procedures. Rates of pelvic organ prolapse are not insignificant following hysterectomy. Re-support of the vaginal apex should be performed at the time of hysterectomy in those with or without a diagnosis of prolapse. Exposure to vaginal apical support procedures may be limited owing to declining rates of vaginal hysterectomy and limited trainee work hours. Surgical models are increasingly being used to supplement operating room experience. The model we present was originally developed for hysterectomy, although its design allows for teaching a variety of apical support procedures that incorporate the uterosacral ligament (USL) for support. We demonstrate performing a USL suspension, internal McCall suture, and modified McCall suture using the model. The model is constructed from readily available supplies, is multi-use, and inexpensive. It allows learners to identify relevant anatomy, understand/visualize surgical steps, and practice suturing technique. Pelvic organ prolapse is common in women, although opportunities to teach apical suspension procedures may be limited. The proposed vaginal surgery simulator can be used to supplement the experience of gynecological surgery trainees with apical suspension procedures.

INTRODUCTION AND HYPOTHESIS To report on clinical presentation, diagnosis, and outcomes after treatment of female urethral diverticulum (UD). METHODS Using a record linkage system, women with a new diagnosis of UD at Mayo Clinic from January 1, 1980, through December 31, 2011, were identified. The presenting symptoms, clinical characteristics, diagnosis, and management of women presenting with UD were recorded. Outcomes after surgery were assessed using survival analysis. All statistical analyses were 2-sided and P values less than 0.05 were considered significant. Statistical analysis was done using SAS version 9.2 and JMP version 9.0 (SAS Institute Inc.). RESULTS A total of 164 cases were identified. Median age at diagnosis was 46 years (range, 21-83). The most common presenting symptom was recurrent urinary tract infection (98, 59.8%), followed by urinary incontinence (81, 49.4%), dysuria (62, 37.8%), dyspareunia (37, 22.6%), and hematuria (15, 9.1%). Examination revealed vaginal mass in 55 (33.5%) of the women. A significant trend was noted toward an increase in use of both magnetic resonance imaging and computed tomography (P < 0.001) along with a progressive decrease in use of urethrogram (P < 0.001) for diagnosis of UD over the years. Among 114 women who underwent surgical treatment for UD, 14(12.3%) women presented with recurrent UD and the 5-year recurrence rate after surgery for UD was 23.4% (95% confidence interval, 13.9-37.0) and a reoperation rate of 17.0% (95% confidence interval, 8.8-30.2) at 5 years. CONCLUSIONS Female UD is a rare and unique condition. Clinical presentation is usually nonspecific, and magnetic resonance imaging is commonly used for confirming the diagnosis. Recurrence is not uncommon, and repeat surgical intervention might be needed.

Objectives The aim of the study was to compare the short-term outcomes of sacral nerve stimulation (SNS) and intradetrusor injection of OnabotulinumtoxinA (Botox) for overactive bladder (OAB) symptoms refractory to behavioral modifications and pharmacologic therapy. Methods This is a retrospective cohort study evaluating the outcomes of SNS and Botox procedures that were performed for refractory OAB symptoms at a tertiary care referral center. The primary outcome was "failure" of treatment that was defined as less than 50% improvement from the baseline symptoms at 6 months. Results Sixty-five SNS and 63 Botox procedures met the inclusion criteria. Women undergoing Botox were more likely to report failure 6 months after the intervention as compared with those undergoing SNS (20 [31.8%] vs 7 [10.8%], P = 0.003; unadjusted odds ratio = 3.85, confidence interval = 1.5-9.93; adjusted odds ratio = 4.47, confidence interval = 1.69-14.4). However, there was no difference in the proportion of women who were started on antimuscarinic medications for persistent urgency urinary incontinence after both procedures (12 [18.5%] women in SNS group and 17 [27%] women in the Botox group, P = 0.249). The most common complication of the SNS procedure was wound related (8 [12.3%]), whereas the most common complication of the Botox procedure was urinary tract infection (31 [49.2%]). Conclusions The SNS resulted in lower failure rates at 6 months when performed for refractory OAB symptoms as compared with the Botox procedure. However, further studies are needed to evaluate the long-term cost-effectiveness of both procedures.

We present a video demonstrating technical considerations and tips for cystoscopic placement of external, lighted, and internal ureteral stents. Cystoscopic ureteral stent placement is useful in cases where difficult pelvic periureter dissection is expected or encountered. In this video, we review cystoscopy basics, our approach to various types of retrograde stent placement, and performing retrograde pyelograms. Traditional external ureteral stent and lighted stent placement for prophylactic purposes are discussed, with attention to understanding stent markings, appropriate resistance, and steps for externalization. Internal, double-J ureteral stent placement with the use of fluoroscopy is initiated with placement of a guidewire. An open-ended ureteral catheter is advanced over the wire in the pelvic portion of the ureter, and a retrograde pyelogram is performed. The wire is reintroduced and the stent advanced to the renal pelvis under fluoroscopy. The proximal curl is confirmed to be in the appropriate position with fluoroscopy. The string attached to the stent is then cut and removed, the guidewire is removed, and the stent is deployed with the distal curl in the bladder. This video reviews key steps for cystoscopic ureteral stent placement in a prophylactic setting, cases of challenging anatomy, or ureteral injury.

Objective 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 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.

We present a video describing the technical considerations for performing an extravesical robotic ureteral reimplantation. A 55-year old woman presented with urinary incontinence secondary to a ureterovaginal fistula after robotic-assisted hysterectomy. After failure of more conservative measures, she proceeded to a robotic ureteral reimplantation. Following port placement, the ureter is identified at the level of the iliac vessels and dissected circumferentially. The ureter is dissected free to the level of the ureterovaginal fistula, transected, and the distal remnant ligated. The ureter is spatulated, a cystotomy created, and a running anastomosis with mucosa-to-mucosa apposition performed over a stent. Care is taken to ensure it is tension free. The integrity of the anastomosis is tested with retrograde filling of the bladder. Postoperatively, a drainage catheter is left to allow for adequate healing. Follow-up imaging is performed to ensure a patent anastomosis. The patient had an uncomplicated postoperative course. A cystogram showed adequate healing at 10 days, and the stent was removed at 6 weeks. A follow-up renal ultrasound 6 weeks later showed no hydronephrosis. Extravesical robotic ureteral reimplantation is a useful technique for managing ureterovaginal fistula; here we highlight pertinent technical considerations.

OBJECTIVES Rectovaginal fistulae (RVF) often represent surgical challenges, and treatment must be individualized. We describe outcomes after primary surgical repair stratified by fistula etiology and surgical approach. METHODS This retrospective cohort study included women who underwent surgical management of RVF at a tertiary care center between July 1, 2001 and December 31, 2013. Cases were stratified according to the following etiology: cancer (RVF-C), inflammatory bowel disease or infectious (RVF-I), and other (RVF-O). Patients with prior surgical treatment of RVF were excluded. Surgical approaches included local (seton, plug), transvaginal or endorectal, abdominal, diversion alone, or definitive (completion proctocolectomy with permanent colostomy or pelvic exenteration). Recurrence-free survival was estimated using the Kaplan-Meier method, and comparisons between subgroups were evaluated based on fitting Cox proportional hazards models. Censoring occurred at last relevant clinical follow-up. Factors contributing to recurrence-free survival were evaluated including age, body mass index, smoking status, fistula etiology, ileostomy, and surgical approach. RESULTS During the study period, 107 women underwent surgical repair of RVF. The most common fistula etiology was RVF-I (54.2%), followed by RVF-O (23.4%), and RVF-C (22.4%). Ninety-four women underwent fistula repair by the local (29.9%), transvaginal/endorectal (25.2%), abdominal approach (19.6%), or diversion alone (13.1%), whereas 13 underwent definitive surgery (12.2%). Recurrence-free survival was significantly different depending on surgical approach (P < 0.001), but not etiology (P = 0.71). Recurrence-free survival (95% confidence interval) at 1 year after surgery was 35.2% (21.8%-56.9%) for the local approach, 55.6% (37.0%-83.3%) for the transvaginal or endorectal approach, 95% (85.9%-100%) for the abdominal approach, and 33.3% (15%-74.2%) for those with diversion only. CONCLUSIONS Recurrence rates after RVF repair are high and did not differ by fistula etiology. Abdominal repair of RVF had significantly fewer recurrences.

OBJECTIVES We aimed to determine the rates of readmission and reoperation for patients undergoing surgery for pelvic organ prolapse (POP). METHODS The American College of Surgeons National Surgical Quality Improvement Program Participant User File was used to select all surgeries performed for POP from 2012 through 2014. The cohort was then reviewed for unplanned readmissions and unplanned reoperations within 30 days of POP surgery. Patient and procedural factors associated with readmission or reoperation were compared using χ analyses and Student t test. Multivariable logistic regression determined independent risk factors for both readmission and reoperation. RESULTS A total of 23,419 patients underwent surgery for POP. Of these, there were 435 (1.9%) readmissions and 341 (1.5%) reoperations within 30 days. Median numbers of days from index procedure to readmission or reoperation were 9 and 8 days, respectively. Those who were readmitted had higher American Society of Anesthesia (ASA) scores, longer operative times, and longer lengths of stay than those who were not readmitted (all P < 0.001). Patients who underwent unplanned reoperation also had higher ASA scores, longer operative times, and longer lengths of stay than those who did not undergo reoperation (all P < 0.01). The most common reasons for readmission were surgical site infection (SSI) (19.3%) and non-SSI (15.9%). The most common reason for reoperation was urologic (27.6%) such as cystoscopy or stent placement. CONCLUSIONS Readmission and reoperation rates are relatively low for patients undergoing surgery for POP. Infection, both SSI and non-SSI, accounted for 35.2% of readmissions. Identification of ASA score of 3 or higher, longer total operating time, and increased length of stay is associated with unplanned readmission and reoperation.

OBJECTIVES This study evaluated our experience after implementing a pelvic floor rehabilitation program including behavioral modification, biofeedback, and vaginal electrogalvanic stimulation (EGS). METHODS This prospective cohort study evaluated outcomes of patients with pelvic floor dysfunction (urinary or defecatory dysfunction, pelvic pain/dyspareunia) who underwent pelvic floor rehabilitation. Patients received 4 to 7 sessions (1 every 2 weeks) including biofeedback and concluded with 30 minutes of vaginal EGS. Surveys assessed subjective changes in symptoms; success was evaluated using a 10-point visual analog scale (VAS) at the final session (10 = most successful). Paired comparisons of responses at baseline and final treatment were evaluated. RESULTS Ninety-four patients were followed up through therapy completion. Treatment indications included urinary (89.4%), defecatory (33.0%), and pelvic pain or dyspareunia (30.9%); 44.7% of patients had a combination of indications. Among women with urinary symptoms, the percentage reporting leakage decreased from 92.9% to 79.3% (P = 0.001), leakage at least daily decreased from 69.0% to 39.5% (P < 0.001), daily urgency with leakage decreased from 42.7% to 19.5% (P = 0.001), daily urgency without leakage decreased from 41.5% to 18.3% (P < 0.001), and median VAS rating (0 = not at all, 10 = a great deal) of daily life interference decreased from 5 to 1.5 (P < 0.001). The median success ratings were 8, 8, and 7 for treatment of urinary symptoms, pelvic pain/dyspareunia, and bowel symptoms, respectively. CONCLUSIONS An aggressive pelvic rehabilitation program including biofeedback with vaginal EGS had a high rate of self-reported subjective success and satisfaction and should be considered a nonsurgical treatment option in patients with pelvic floor dysfunction.

OBJECTIVE The optimal suture selection for mesh attachment during robotic sacrocolpopexy (RSC) is currently unknown. Here, we sought to evaluate the outcomes of RSC using absorbable sutures for vaginal and sacral mesh attachment. METHODS We retrospectively reviewed 132 RSC surgeries that were performed for vaginal vault prolapse in the Division of Gynecologic Surgery at our institution from February 2007 to December 2013. All cases were performed with absorbable suture (polyglactin) for vaginal and sacral mesh fixation. Sacrocolpopexy failure was defined as patients undergoing either repeat prolapse surgery or pessary use for recurrent prolapse. The durability of RSC was assessed via Kaplan-Meier method. RESULTS The median age at surgery was 61.1 years (interquartile range [IQR], 55.6-68.2) and the median length of postoperative follow-up was 33 months (IQR, 15.7-57). The median body mass index was 26.5 kg/m (IQR, 24.3-29.7). During follow-up, 10 patients underwent prolapse retreatment. There were 2 apical recurrences, 4 distal anterior recurrences, 2 posterior recurrences, and, in 2 cases, the location was unknown. One apical recurrence was confirmed to be secondary to detachment of the mesh from the sacral promontory. Among those with recurrence, the median time to recurrence was 15.5 months (IQR, 4.22-35.9). Overall, the 1-year and 3-year freedom from repeat surgery rates were 96% and 93%, respectively. CONCLUSIONS With a median follow-up of 33 months, the use of absorbable suture for both vaginal and sacral attachments during RSC is effective. Further studies evaluating suture selection and mesh attachment techniques for RSC are needed.

We present a video describing the technical considerations for performing a total colpocleisis in the management of symptomatic post-hysterectomy pelvic organ prolapse.A 76-year old female presented with pelvic pressure and the presence of a palpable vaginal bulge. She had significant bother and had previously failed use of a pessary. She wasnot sexually active, with no plans for future sexual activity. Her medical history was significant for coronary artery disease with prior myocardial infarction. She had high-grade vaginal vault prolapse, without occult incontinence. After discussing observation, pessaries, restorative and obliterative procedures, she elected to undergo colpocleisis. Following hydrodissection with lidocaine with epinephrine, a quadrant-based dissection was performed to remove the vaginal epithelium circumferentially. Following this, serial purse string sutures were used to reduce the prolapse, with meticulous hemostasis. The vaginal epithelium was then closed transversely. Next, a perineorrhaphy was performed. The midline was plicated and the perineal body reconstructed.The patient had an uncomplicated postoperative course. At six-week follow-up she had no evidence of recurrent prolapse and was voiding without difficulty.Colpocleisis can provide excellent anatomic and subjective outcomes. Our goal is to highlight pertinent technical considerations in order to optimize patient outcomes.

To evaluate the carcinogenic potential of implanted synthetic mesh midurethral slings in the treatment of female stress urinary incontinence. We identified female patients undergoing implantation of mesh materials for stress urinary incontinence at our institution from 1 January 2002 to 31 December 2012. This was accomplished by querying the medical records for CPT code 57288 (“sling operation for stress incontinence”) and a subsequent chart review to identify patients who underwent synthetic mesh sling placement. Medical records were then evaluated for the documentation of bladder, urethral, vaginal, cervical, uterine or ovarian cancers via the International Classification of Disease (ninth edition) coding. A chart review of patients with a cancer diagnosis was performed for verification of the diagnosis and evaluation of the temporal relationship with sling placement. During the study period, 2,474 patients underwent polypropylene midurethral sling placement. The median age was 57 years (IQR 47, 69) and the median follow-up was 60 months (IQR 23.3, 94.9). Overall, 51 patients also had a cancer diagnosis (8 bladder cancers, 7 vaginal malignancies, 8 ovarian carcinomas, 26 endometrial cancers, 2 cervical malignancies); however, only 2 cancers (0.08 %, 2 out of 2,474) developed following sling placement (a vaginal melanoma 3 years after sling placement and an ovarian tumor 1 year after sling placement). No cases of sarcoma formation, bladder, urethral or squamous cell carcinomas were identified. With a median follow-up of 5 years after synthetic midurethral sling placement, development of pelvic malignancy was rare (0.08 %) and unlikely to be secondary to foreign body reaction from the implanted material.

We sought to determine the incidence of venous thromboembolism (VTE) in patients undergoing surgery for pelvic organ prolapse (POP) based on surgical approach. The American College of Surgeons National Quality Improvement Program (NSQIP) database was used to select all surgeries performed for POP from 2005 to 2013. CPT-4 codes were grouped based on surgical approach: vaginal (VAG), laparoscopic sacrocolpopexy (LSC), or open abdominal sacrocolpopexy (ASC). Patient demographics, preoperative American Society of Anesthesiologists (ASA) classification system scores, and 30-day postoperative complications were obtained. Of the 26,103 women who underwent surgery for POP, 21,311 (81.7 %) underwent VAG, 3,346 (12.8 %) LSC, and 1,426 (5.5 %) ASC. VTE occurred in 36 patients (0.17 %) in the VAG group, 8 (0.24 %) in the LSC group, and 9 (0.63 %) in the ASC group. The ASC group had a significantly higher incidence of VTE compared with the VAG group (p

Introduction Sexual function through pregnancy and the postpartum period is an important aspect of quality of life. Despite this, prospective studies are limited, and the impact of body image on sexual function has not been explored. Aim To prospectively assess the effects of pregnancy on sexual function, and explore causative factors for sexual function alterations such as body image and pelvic floor symptoms. Materials and Methods Pregnant women completed the questionnaires in the first and third trimester and at 6 months postpartum. These included general information, questions regarding sexual activity and practices, and five validated indices: the Female Sexual Function Index (FSFI), the Body Exposure during Sexual Activities Questionnaire, short forms of Urogenital Distress Inventory and Incontinence Impact Questionnaire, and the Fecal Incontinence Quality of Life Scale. Main Outcome Measures An assessment of the FSFI domains through the 6 months postpartum and relationships between sexual function, body image, and pelvic floor symptoms. Results One hundred seven women were enrolled, 63 completed the final questionnaire. Sexual function declined through pregnancy and was not recovered by postpartum ( P = 0.017); sexual frequency was highest prior to becoming pregnant ( P P = 0.01). In early pregnancy, low sexual function was associated with impaired body image, while in the postpartum period, worse urinary symptoms correlated with poor FSFI. Conclusion Sexual function worsens during pregnancy and is not recovered by the 6 months postpartum; poor scores may be attributable to low body image and urinary complaints. Pauls RN, Occhino JA, and Dryfhout VL. Effects of pregnancy on female sexual function and body image: A prospective study. J Sex Med 2008;5:1915–1922.

Objective We aimed to determine whether pelvic organ prolapse quantification measurements of genital hiatus (gh) or perineal body (pb) obtained in the late third trimester are predictors of obstetric perineal laceration in nulliparous women. Methods Nulliparous women with singleton gestation were prospectively recruited after 35-week gestation, and gh and pb measurements were obtained. After delivery, determination of the presence and degree of perineal laceration were recorded. Correlation of gh and pb measurements with risk of perineal laceration (defined as second, third, or fourth degree) was assessed using the Wilcoxon rank sum test. Results We recruited 224 patients and 133 met inclusion criteria after delivery. The mean (SD) age was 27.2 (4.0) years and mean (SD) prepregnancy body mass index was 24.1 (4.6) kg/m. Seventy patients (52.6%) had either a second-degree (n = 64) or third-degree (n = 6) laceration. No fourth-degree lacerations were recorded. We found no significant difference in the median gh (3.5 vs 3.0 cm, P = 0.34) and pb (3.5 vs 3.5 cm, P = 0.54) measurements among women with and without perineal lacerations. Conclusions Our data suggest that antenatal measurement of gh and pb does not correlate with the risk of obstetric perineal laceration in nulliparous patients undergoing spontaneous vaginal delivery.

The aim was to evaluate the learning curve of robotic sacrocolpopexy, adjusted for surgical risk.The charts of 145 robotic sacrocolpopexies performed by urogynecologists at Mayo Clinic, Rochester, MN, USA, from 2007 to 2013, were reviewed. Outcomes of interest included operative time, intraoperative complications, and postoperative complications with a Clavien-Dindo grade 2 or higher. Risk-adjusted cumulative summation analysis was performed by comparing a calculated complication risk score with observed patient outcomes, and then cumulatively recalculating the rate of expected vs observed complications after each procedure. Proficiency was defined as the point at which the surgeon's complication rates were better than expected, given the patient's risk factors.The median operative time decreased significantly, from 5.3 to 3.6 h, during the 7-year period, and plateaued after the first 60 cases. A higher ASA classification was associated with an increased risk of intraoperative complications (p = 0.02), and a higher Charlson comorbidity index was associated with an increased risk of intraoperative or postoperative complications (p = 0.01). In risk-adjusted CUSUM analyses, accounting for these factors, and for body-mass index and vaginal parity, proficiency was identified at 55 cases for intraoperative complications and 84 cases for intraoperative or postoperative complications.Operative time plateaued after the first 60 cases, whereas complication rates continued to decrease beyond this. Proficiency, as determined by a risk-adjusted CUSUM analysis for complication rates, was achieved after approximately 84 cases. Evaluation of postoperative complications in addition to intraoperative complications, in a risk-adjusted model, is critical in depicting the surgical learning curve.

Mentor Corporation's ObTape has been associated with considerable morbidity. An unacceptably high exposure rate has been noted, and in some cases, multiple procedures may be necessary for complete mesh removal. We evaluated a patient who had prior ObTape placement complicated with persistent vaginal discharge and granulation tissue formation related to persistent mesh exposure (3Bc-T2-S2) followed by sinus tract formation (6Cd-T3-S3) according to the International Urogynecological Association Classification. We performed a three-incision approach (abdominal, vaginal, and groin) for the complete removal of the retained portion of the transobturator tape. This three-incision technique represents a viable option for removal of transobturator tape causing persistent clinical issues.

Objectives Vaginal shortening and narrowing is an uncommon complication of vaginal reconstructive surgery for prolapse and may cause sexual dysfunction and dyspareunia. We hypothesize that vaginal length, caliber, and sexual function will remain unchanged between the initial (6 weeks to 6 months) and medium-term (18-36 months) postoperative periods. Methods Women who had previously undergone native tissue vaginal reconstructive surgery for symptomatic pelvic organ prolapse and did not undergo intentional vaginal shortening and narrowing were invited to participate by completing a survey and undergoing a physical examination. Vaginal obturators of variable diameters were used to measure vaginal length and caliber. Sexual function was assessed using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12. Women were asked to complete the same checklist assessing barriers (if not sexually active) or interfering factors (if sexually active) to sexual activity. Results Survey results were available from 41 women with mean ± SD age at surgery of 63.7 ± 10.6 years. Among those sexually active at both postoperative periods (22 women), mean Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 scores were unchanged between the initial and medium-term postoperative periods (34.1 ± 6.0 vs 32.9 ± 6.0; P = 0.19). Vaginal dryness was the most common interfering factor to sexual activity. Vaginal length and caliber were unchanged between measurements at the initial postoperative and the medium-term postoperative periods. Conclusion There was no significant change in vaginal anatomy measurements or sexual function between initial (6 weeks to 6 months) and medium-term (18-36 months) postoperative periods after vaginal reconstructive surgery.

OBJECTIVE : This study aimed to validate a visual analog scale (VAS) form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). METHODS : This was a planned secondary analysis of a vaginal anatomy and sexual function study. All women undergoing vaginal reconstruction between October 2008 and December 2009 were asked to participate. We planned for an analysis of 30 women for this validation. Preoperatively, sexually active participants completed a questionnaire containing a PISQ-12 in Likert (0-4) and VAS (0-10) format. Within 30 days, participants completed a PISQ-12 in VAS form only for evaluation of test-retest reliability. At 6 months after surgery, participants completed the PISQ-12 in both the Likert and VAS forms. For each item on the PISQ-12, the Spearman rank correlation coefficient was used to estimate the correlation between the Likert and VAS formats using the responses from the same assessment period (before or after surgery). The intraclass correlation coefficient was estimated to assess the test-retest agreement. RESULTS : A total of 43 women completed the preoperative questionnaire, 25 completed the retest, and 37 completed the postoperative questionnaire. When PISQ-12 scores were compared between the Likert and VAS forms, correlation values were 0.88 preoperatively and 0.91 postoperatively. Test-retest reliability was high with an intraclass correlation coefficient of 0.87. Most women preferred the Likert version (71.4% preoperatively and 55.0% postoperatively). CONCLUSIONS : The VAS form of the PISQ-12 is both reliable and reproducible and avoids the limitations of the Likert scale.

OBJECTIVES The aim of this study was to evaluate the feasibility of teaching clean intermittent self-catheterization (CISC) in an outpatient setting to women planning surgery for pelvic organ prolapse (POP) and/or urinary incontinence (UI). METHODS This was a prospective observational study of 55 women who planned surgical correction of POP and/or UI. All women were taught CISC as part of their preoperative education. The ability to learn CISC and the amount of time needed to teach CISC were recorded. Multivariate modeling, χ2 test, Fisher exact test, and Kruskal-Wallis analysis of variance were used for statistical analysis. RESULTS Of the 55 subjects consecutively enrolled, 51 subjects (93%) were able to learn CISC and demonstrate competency (P < 0.00001). Four subjects (7%) were unable to learn CISC. The median time to teach CISC with demonstrated proficiency was 3.7 minutes (range, 1.8-7.4 minutes). Of the subjects who learned CISC and had surgery, the mean (SD) time in days from preoperative teaching to the postoperative voiding trial was 16 (11) days (range, 2-39 days). Of the 41 subjects who completed the postoperative voiding trial and had data recorded, 33 (80%) were able to self-catheterize without nurse assistance or with minimal verbal coaching, whereas 8 (20%) subjects required hands-on nursing assistance or were unable to perform CISC (P < 0.001). CONCLUSIONS Clean intermittent self-catheterization can be taught to most patients undergoing POP/UI surgery in a short time (median, 3.7 minutes). The overwhelming majority of patients are able to retain the CISC skill weeks after being taught in the clinic.

Female genital mutilation (FGM) is a violation of human rights; yet, more than 100 million females are estimated to have undergone the procedure worldwide. There is an increased need for physician education in treating FGM. Female pelvic surgeons have a unique opportunity to treat this population of patients. Here, we depict the classification of FGM and a general approach to FGM reversal. We specifically address the procedure of type III FGM reversal, or defibulation. In this video, we first highlight the importance of the problem of FGM. Next, we present the classification of FGM using an original, simple, schematic diagram highlighting they key anatomic structures involved in the four types of FGM. We then present a simple case of reversal of type III FGM, a procedure also known as defibulation. After depicting the surgical procedure, we discuss clinical results and summarize key principles of the defibulation procedure. Our patient was a 25-year-old woman who had undergone type III FGM as a child in Somalia. She desired restoration of vaginal function. We performed a reversal, and her postoperative course was uncomplicated. By 6 weeks postoperatively, she was able to engage in sexual intercourse without dyspareunia. FGM is a problem at the doorsteps of female pelvic medicine and reconstructive surgery. Our video demonstrates a basic surgical approach that can be applied to simple cases of type III FGM presenting to the female pelvic surgeon.

The study’s objectives were to determine changes in vaginal length and caliber after vaginal surgery and to correlate changes with sexual function. This prospective study measured vaginal length and caliber before and immediately after vaginal surgery and at 5- to 8-week follow-up. A sexual function questionnaire was administered preoperatively and 6 months postoperatively. Ninety-two women were enrolled (mean age, 64 years); 44 (47.8%) were sexually active. The most common procedure was Mayo-McCall culdoplasty in 85 women (92.4%). Fourteen (15.2%) had intentional vaginal shortening and narrowing (coning). Mean vaginal length changed from 10.4 cm preoperatively to 8.7 cm at 5- to 8-week follow-up in women not having coning. Mean vaginal caliber changed from 3.2 to 2.8 cm. Preoperative and postoperative sexual function questionnaire scores did not correlate with vaginal measurements. Vaginal shortening and narrowing occurred after vaginal surgery; sexual function was unchanged.

This article represents a general overview of therapies for urinary urgency, frequency, and overactive bladder, with specific emphasis on sacral neuromodulation. The history of sacral neuromodulation is discussed along with an update of the current literature. Future directions for neuromodulation of the pelvic floor also are discussed.

Impact of pregnancy on pelvic symptom-related quality of life and body image has not been previously documented. We hypothesize that pregnancy will have a negative impact on pelvic symptoms and body image. Pregnant subjects completed questionnaires in the first (S1) and third trimester (S2) and 6 months postpartum (S3) including: Body Exposure During Sexual Activities Questionnaire, Urogenital Distress Inventory, Incontinence Impact Questionnaire, and Fecal Incontinence Quality of Life Scale. Urinary symptoms worsened through pregnancy with improvement postpartum. However, quality of life impact of fecal incontinence was stable. Although some associations between low body image and maternal weight, urinary distress, and bowel complaints were suggested, no significant relationships were noted. Poorest body image was noted in the postpartum period. Urinary symptoms worsen during pregnancy with recovery postpartum, while body image suffers most following pregnancy.

This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient's prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula.Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.