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The annual percentage of hysterectomies performed with robotic-assisted laparoscopy has steadily increased since the U.S. Food and Drug Administration (FDA) approved the platform for gynecologic su...

Objective: The aim of this study was to highlight the safety of OnabotulinumtoxinA (BTA) injections, with or without concurrent pudendal nerve block, in treating women with myofascial pelvic pain (MFPP). Design: This was a retrospective cohort study. Setting: The review was conducted in a tertiary care academic center. Participants/Materials: We conducted a chart review of patients who were diagnosed with MFPP and treated with BTA with or without pudendal nerve block between January 2010 and February 2022. Methods: BTA was injected transvaginally into the pelvic floor muscle group. The primary outcomes were adverse events after BTA injections, and the secondary outcome was the effect of concomitant pudendal nerve block at the time of BTA injections. Results: The cohort included 182 patients; 103 (56.6%) received BTA injections with pudendal nerve block, and 79 (43.4%) received BTA alone. There were no significant demographic differences between the two groups. Post-treatment complications of BTA administration included worsening of pelvic pain (11.5%), constipation (6.6%), urinary tract infection (2.7%), urinary retention (3.8%), and fecal incontinence (2.7%). No statistical difference was noted in the number of phone calls, patient-initiated electronic messages, emergency room visits, or clinic visits for both groups within 30 days post-treatment. The mean number of total injections was 1.6 in the BTA-only group and 1.7 in the BTA with pudendal block group (p = 0.421). Median time to re-intervention with a second BTA injection was 6.0 months; 5.6 months in the BTA with pudendal block group; and 6.8 months in the BTA-only group, p = 0.46. There were 63 re-intervention events after BTA injections. Limitations: Limitations of our study include the retrospective design making it vulnerable to missing or incomplete data available for review. Conclusion: OnabotulinumtoxinA is beneficial in treating women with MFPP; with a duration of therapeutic effect of approximately 6 months. The use of a concurrent pudendal nerve block did not impact clinical outcomes.

To gather validity evidence for and determine acceptability of Surgical Science-Simbionix Hysterectomy Modules for the DaVinci Xi console simulation system (software; 3D Systems by Simbionix [now Surgical Science-Simbionix], Littleton, CO, and hardware; Intuitive Surgical, Inc., Sunnyvale, CA) and evaluate performance benchmarks between novice and experienced or expert surgeons.Prospective education study (Messick validity framework).Multicenter, academic medical institutions.Residents, fellows, and faculty in obstetrics and gynecology were invited to participate at 3 institutions. Participants were categorized by experience level: fewer than 10 hysterectomies (novice), 10 to 50 hysterectomies (experienced), and more than 50 hysterectomies (expert). A total of 10 novice, 10 experienced, and 14 expert surgeons were included.Participants completed 4 simulator modules (ureter identification, bladder flap development, colpotomy, complete hysterectomy) and a qualitative survey. Simulator recordings were reviewed in duplicate by educators in minimally invasive gynecologic surgery using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) rating scale.Most participants felt that the simulator realistically simulated robotic hysterectomy (64.7%) and that feedback provided by the simulator was as or more helpful than feedback from previous simulators (88.2%) but less helpful than feedback provided in the operating room (73.5%). Participants felt that this simulator would be helpful for teaching junior residents. Simulator-generated metrics correlated with GEARS performance for the bladder flap and ureter identification modules in multiple domains including total movements and total time for completion. GEARS performance for the bladder flap module correlated with experience level (novice vs experienced/expert) in the domains of interest and total score but did not consistently correlate for the other procedural modules. Performance benchmarks were evaluated for the bladder flap module for each GEARS domain and total score.The modules were well received by participants of all experience levels. Individual simulation modules appear to better discriminate between novice and experienced/expert users than overall simulator performance. Based on these data and participant feedback, the use of individual modules in early residency education may be helpful for providing feedback and may ultimately serve as 1 component of determining readiness to perform robotic hysterectomy.

BACKGROUND Coccygodynia is a painful condition of the tailbone that occurs more commonly in females. The association of coccyx pain with pelvic floor symptoms and the prevalence of coccyx pain in women with pelvic pain has not previously been reported. OBJECTIVE To identify the prevalence of coccygodynia in women with pelvic pain and to describe the association of coccygodynia with pelvic floor examination findings and symptoms. DESIGN Retrospective cohort analysis. SETTING Tertiary medical institution. PARTICIPANTS One hundred twenty-seven women presenting for outpatient pelvic floor physical therapy treatment who underwent vaginal and rectal pelvic floor examination. MAIN OUTCOME MEASURES Prevalence of coccygodynia, pain scores, association of coccygodynia with other comorbidities and diagnoses, and association of coccygodynia with physical examination findings. RESULTS Sixty-three (49.6%) of 127 women with pelvic pain presented with coccygodynia and 64 (50.4%) did not. Women with coccygodynia had significantly higher rates of muscle spasm (50.8% vs. 31.2%, p = .025) higher visual analog scale pain scores (median 5 vs. 3, p = .014), higher rates of outlet dysfunction constipation (31.7% vs. 10.0%, p = .032), and higher rates of fibromyalgia (15.9% vs. 3.1%, p = .014). On pelvic examination, women with coccygodynia were significantly more likely to have sacrococcygeal joint hypomobility (65.1% vs. 14.1%, p

Fecal incontinence often is underreported and can be associated with both social embarrassment and isolation. As patients often do not proactively discuss their symptoms, healthcare providers should screen for this distressing condition. The cause of fecal incontinence often is multifactorial, so no single therapy can guarantee perfect, risk-free outcomes. This article reviews the limited therapies for managing fecal incontinence, including a minimally invasive vaginal control device that may offer hope for managing fecal incontinence in women.

BACKGROUND The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy. METHODS This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction. RESULTS A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P

Study Objective To highlight a safe and effective technique of the Lefort Colpocleisis for treating pelvic organ prolapse in an elderly patient. Design Educational Video. Setting OR. Patients or Participants The index patient is an 82-yo G2P1011 patient with symptomatic stage III pelvic organ prolapse; the anterior compartment was the leading edge. Due to the prolapse the patient was unable to exercise and walk as much as she desired. She failed an initial trial of ring pessary. After appropriate counseling, the patient opted for surgical intervention via a Lefort Colpocleisis with the understanding that this would preclude vaginal intercourse in the future. Preoperative evaluation with cystoscopy, urodynamic studies and a pelvic ultrasound were all within normal limits. We started the procedure by marking rectangular areas on the anterior and posterior vagina. The marked areas are then removed by careful sharp and blunt dissection. The edges of the rectangle and the denuded vaginal mucosa were then closed; leaving laterally created tunnels for drainage of cervical mucus. As successive sutures were placed; it was ensured that the knots were within the epithelial lined tunnels. This carefully maneuvered technique allowed the uterus and vaginal apex to be gradually turned inward. A bladder neck plication suture was then placed due to the high risk of stress incontinence accompanying these cases. A perineorrhaphy was completed to narrow the vaginal introitus. A cystoscopy was then performed confirming ureteral patency and excluding lower urinary tract injury. At her postoperative visit the patient had resolution of her symptoms and was pleased with the outcome of her surgery. Interventions LeFort Colpocleisis. Measurements and Main Results N/A. Conclusion This technique is a good approach for the management of pelvic organ prolapse in elderly patients or those who are not candidates for major reconstructive surgery.

Introduction A retrospective chart review was conducted of visual analog scale (VAS) scores completed before and after trigger point injections (TPIs) for pelvic floor myofascial spasm to evaluate response. Methods Sixty-eight female patients who underwent TPIs from October 9, 2007 to March 12, 2015 were included. The primary end point was the difference between scores. Secondary analyses were conducted for patients who needed repeat TPIs. Descriptive and paired t test analyses were used. Results The key result was an improvement in VAS scores for 65% (44/68) of patients (pConclusions We report on 68 women who underwent TPIs, with an improvement in VAS pain scores in 65%. It appears that TPIs for pelvic floor myofascial spasm are successful in reducing pain scores for patients who are refractory to primary therapy.

Study Objective The objectives of this video are to demonstrate normal findings at the time of cystourethroscopy, show examples of common benign findings within the bladder and urethra, and to show lesions that warrant additional investigation. We hope to provide examples of common benign and malignant findings to gynecologic surgeons to assist with recognition if they incidentally found. Design N/A Setting Tertiary academic hospital with a high-volume gynecologic surgery practice Patients or Participants The images shown in the video are taken from a variety of patients undergoing cystoscopy by two urogynecologists. Interventions Images were obtained at the time of surgery for educational purposes Measurements and Main Results This video demonstrates the equipment and steps of performing cystourethroscopy. We review examples of the following benign anatomic variants: shaggy urethral fronds, squamous metaplasia, cystitis cystica, bladder trabeculations, ureterocele, bladder diverticula, bladder wall cysts, ureteral orifice cysts, hypervascularity, duplicated collecting systems, foreign bodies, and fistulas. We also review two examples of neoplastic findings, including urothelial papilloma and papillary urothelial carcinoma. Conclusion Cystoscopy can be a useful procedure in the office and operating room. Gynecologic surgeons should be familiar with normal cystoscopy findings. If abnormalities are found, it is the surgeon's responsibility to document and refer the patient for additional testing if indicated.

To demonstrate the process for establishing or refuting validity for the Limbs and Things hysterectomy model.Prospective study using Kane's framework for establishing validity (Canadian Task Force classification: II-2).Total laparoscopic hysterectomy (TLH) assessments completed in the operating room (OR) and simulation at 3 academic medical centers.Obstetrics and gynecology residents (n = 26 postgraduate years 3-4), a gynecologic oncology fellow (postgraduate year 5), and a gynecology oncology attending.Participants were rated with the myTIPreport feedback application by nonblinded faculty in the OR after TLH. In-person, simulation-based assessments were provided by 2 faculty members blinded to experience level using myTIPreport and Global Operative Assessment of Laparoscopic Skills (GOALS). Videos of simulated TLHs were rated by 2 minimally invasive gynecology fellows.OR scores for TLH steps were significantly higher than simulation assessments (p .001) with "competent" marked more frequently in the OR. Number of robotic + conventional TLHs performed as primary surgeon was not significantly correlated with OR myTIPreport rating (Spearman r = .30, p = .14) but was significantly correlated with myTIPreport and GOALS in-person simulation ratings (Spearman r = .39-.58, p = .001-.04). Agreement between in-person simulation rater 1 and 2 myTIPreport assessments was 71.4% (weighted κ, .68; 95% confidence interval, .45-.90), and intraclass correlation for the GOALS overall assessment was .71 (95% confidence interval, .46-.85), indicating substantial agreement. Blinded video reviews showed similar agreement (73.1%) between raters but less correlation with experience (Spearman r = .32-.42, p = .11-.03) than in-person reviews. Using area under the receiver operating characteristic curve, mean score for the individual components of GOALS that best differentiated myTIPreport noncompetent and competent levels of performance was 4.3. Feedback acceptability and model realism were rated highly.The scoring and generalization validity inferences for Limbs and Things and myTIPreport are supported when global assessments of performance are evaluated but not for individual components of the assessment instruments.

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patient's risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patient's quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.

Study Objective This video shows a new technique for the surgical management of fecal incontinence using the Fenix Continence Restoration System (TORAX Medical Inc, Shoreview, MN) in 2 patients. Design A step-by-step explanation of the video using videos and pictures (educational video) for surgeons (Canadian Task Force classification III). Setting The use of the Fenix System received United States Food and Drug Administration approval under a humanitarian device exemption and can be used with institutional review board approval in patients who have failed previous medical and surgical management of fecal incontinence. The device is a small, flexible band of interlinked titanium, magnetic beads on a titanium string that is placed using a perineal approach around the anal canal. Increased intra-abdominal pressure opens the beads to allow for the passage of stool. Interventions Placement of the device was performed in 2 patients. Case 1 is a 63-year-old woman with a long-standing history of fecal incontinence who failed sphincteroplasty, sacral neuromodulation, and an artificial sphincter cuff and pump. Case 2 is a 60-year-old woman with a long-standing history of fecal incontinence secondary to radiation therapy for rectal cancer who failed physical therapy and sacral neuromodulation. Conclusion Both Fenix Continence Restoration Systems were placed successfully. Long-term postoperative effectiveness is currently being evaluated.

To compare patient slide in Trendelenburg position using egg-crate foam or gel pad. This randomized trial compared slide on friction pads during Trendelenburg position for robotic and laparoscopic gynecologic procedures in 61 patients at the Mayo Clinic Florida between March 11, 2010 and May 31, 2011. Data was analyzed using Student's t test with significance defined as p ≤ 0.05. There was no significant difference in mean slide according to pad type (foam 3.0 ± SD 2.1 cm; gel 4.5 ± SD 4.0 cm, p = 0.08). Minor complaints occurred in 10 % of patients, and did not differ by group (p = 0.4). Most complaints (98 %) were transient shoulder or neck pain. A single patient had both transient right hand numbness and right lateral thigh paresthesia. We assessed outcomes by chart review from the inpatient care and postoperative evaluation notes (mean 44 ± SD 17 days), and by review of any intervening notes that occurred before the study's end (mean 345 ± SD 116 days). Trendelenburg-related slide is equivalent on either egg-crate foam or gel pad.

Objective: The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction. Study Design: Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis). Results: All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding. Conclusion: The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence. (Am J Obstet Gynecol 2002;187:1494-1500.)

Study Objective Determine use patterns and success rates for office diagnostic hysteroscopy with the 2.9 mm Storz TROPHYSCOPE® and handheld portable Cooper Surgical Endosee device in a clinic setting. Design Prospective cohort study of a hysteroscopy quality improvement database. Setting Gynecology clinic in a tertiary care center. Patients or Participants Patients undergoing office hysteroscopy with either the Storz Trophyscope or Cooper Surgical Endosee device. Interventions Diagnostic office hysteroscopy. Measurements and Main Results Of the 172 office hysteroscopies, 78 utilized the Trophyscope, with 8 (10%) being inadequate, while 94 utilized Endosee, with 13 (14%) being inadequate (p=.64). Of the 13 inadequate Endosee hysteroscopies, 3 (23%) were due to visualization, 5 (39%) due to patient intolerance, 3 (23%) due to cervical stenosis, and 2 (15%) due to both patient intolerance and stenosis. Of the 8 inadequate Trophyscope hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis (p=0.14). Of the 151 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR) with hysteroscopy or hysterectomy (Table 1). Of these, 27 (84%) of 32 Endosee cases and 15 (75%) of 20 Trophyscope cases were in agreement with findings from the OR procedure (p=0.48). Conclusion There is no difference in adequate visualization or pathologic diagnoses with the Endosee and TrophyScope devices in this prospective cohort. Larger, adequately powered studies are needed to confirm the sensitivity and specificity for these newer, disposable office hysteroscopic devices.

Background Chronic tubo-ovarian abscess is an uncommon finding in postmenopausal women. This abscess may rupture or fistulize to adjacent organs into the ischiorectal space. Case A gravida three, para three, postmenopausal woman with extensive sigmoid diverticulosis presented with perianal fistula of 2 years' duration. Magnetic resonance imaging showed the tract to have a supralevator origin adjacent to the sigmoid colon. She had no recent instrumentation other than preoperative colonoscopy. Intraoperatively, the fistula tract origin was noted to be from a right tubo-ovarian abscess. She was treated with right salpingo-oophorectomy and tract excision/sealing. At 4-month follow-up, the fistula tract was healed with no further drainage. Conclusions Tubo-ovarian abscess should be considered in the differential diagnosis of supralevator fistula in postmenopausal women when no other source can be localized.

Purpose of review The first sacral nerve stimulators implanted by Tanagho and Schmidt (1981) were performed for the indications of urinary urge incontinence, urgency-frequency, and nonobstructive urinary retention. Since that time, observations have been made for benefits beyond voiding disorders. These additional benefits have included re-establishment of pelvic floor muscle awareness, resolution of pelvic floor muscle tension and pain, decrease in vestibulitis and vulvadynia, decrease in bladder pain (interstitial cystitis), and normalization of bowel function. Recent findings Therapy for fecal incontinence in patients with a structurally intact sphincter mechanism appears to be very promising. Investigators agree that there is a role for sacral nerve stimulation in patients with urge fecal incontinence that have failed conservative efforts. Objective manovolumetric testing shows an increase in resting pressure, an increase in voluntary contraction pressure, a decrease in rectal volumes which cause first urge, a decrease in rectal volume to initiate first urge to defecate, and an increase in duration of maximum squeeze pressure. Intractable interstitial cystitis is defined as patients that have failed conventional therapy. Historically, the only option remaining was extirpative surgery or diversion. Maher et al. reported on patients with intractable interstitial cystitis who had undergone sacral nerve stimulation. They found that 73% of these patients had a reduction in pelvic pain, daytime frequency, nocturnal urgency and an increase in average voided volumes. The final area of interest concerns refractory pelvic pain. Siegal et al. reported a decrease in severity, number of hours of pain, and improved quality of life measures in patients who underwent transforamenal sacral nerve stimulations. These patients had all failed conventional pain therapy. Summary While the data are encouraging in these new arenas of pelvic floor disorders, investigators acknowledge the need for multicenter, statistically powered studies to evaluate the validity of these findings.

Objective To evaluate the safety and clinical effectiveness of intravaginal misoprostol, a synthetic prostaglandin E 1 analogue, for labor induction in gravidas with premature rupture of membranes (PROM) at term. Methods One hundred forty-one pregnant women with term PROM were assigned randomly to one of two induction groups: 1) intravaginal misoprostol or 2) intravenous oxytocin by continuous infusion. Results Seventy subjects were allocated to the misoprostol group and 71 to the oxytocin group. The mean (± standard deviation) interval from induction to delivery was significantly shorter in the misoprostol group (416 ± 276 compared with 539 ± 372 minutes; P = .04). In 85.7% of patients in the misoprostol group, only one dose was required. Intrapartum complication rates, mode of delivery, and neonatal or maternal adverse event rates were similar in the two treatment groups. Uterine tachysystole occurred more frequently with misoprostol than with oxytocin (28.6% compared with 14.0%; P Conclusion Intravaginal administration of misoprostol induces labor safely and effectively in patients with PROM at term.