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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

The aim of this study was to investigate trends and outcomes of ambulatory minimally invasive sacrocolpopexy (MISC) using data from a contemporary multicenter nationwide cohort.We used the American College of Surgeons National Surgical Quality Improvement Program database to identify women who underwent nonemergent MISC (laparoscopic and robotic) from 2012 to 2018. Exclusion criteria were age18 or ≥90 years, rectal prolapse, postoperative discharge day ≥3, and concomitant hysterectomy, transvaginal mesh repair, colpocleisis, and/or colorectal surgery. Baseline demographics and 30-day outcomes were compared between patients who underwent same-day discharge (SDD; discharge on postoperative day [POD] 0) and those discharged on POD 1-2 using Kruskal-Wallis, Fisher exact, and Pearson χ2 tests. A 2-sided Cochran-Armitage trend test assessed SDD over time, and person-years methodology was used to assess readmission rates. Multivariable logistic regression and Cox proportional hazards modeling evaluated associations between SDD and postoperative outcomes. We hypothesized that SDD increased over the study time frame and is not associated with adverse outcomes.Of 2,928 women, 362 (12.4%) were SDD, and 2,566 (87.6%) were discharged POD 1-2. The proportion of SDD nearly quadrupled over time (5.6% [2012], 20.6% [2018]; P0.001). The SDD group was younger (mean age, 61.9 vs 63.6; P = 0.04), with lower proportion of American Society of Anesthesiologists class III or higher (21.8% vs 27.5%; P = 0.02) and hypertension (37.3% vs.46.5%; P0.001), shorter total operation time (median, 142 vs 172 minutes; P0.001), and fewer concomitant slings (21.5% vs 33.0%; P0.001). Outcomes were similar for SDD: 30-day overall complications (3.0% vs 4.4%; P = 0.23), readmissions (1.1% vs 2.0%; P = 0.28), and reoperations (1.1% vs 0.9%; P = 0.55) and persisted with multivariable analysis.Ambulatory MISC significantly increased during the study period and appears safe and feasible in select patients.

The aim of this study was to perform a cost-effectiveness analysis comparing the management for ongoing voiding dysfunction after midurethral sling placement, including early sling loosening and delayed sling lysis.A Markov model was created to compare the cost-effectiveness of early sling loosening (2 weeks) versus delayed sling lysis (6 weeks) for the management of persisting voiding dysfunction/retention after midurethral sling placement. A literature review provided rates of resolution of voiding dysfunction with conservative management, complications, recurrent stress urinary incontinence, or ongoing retention, as well as quality-adjusted life years (QALYs). Costs were based on 2020 Medicare reimbursement rates. Incremental cost-effectiveness ratios were compared using a willingness-to-pay threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed.At 1 year, early sling loosening resulted in increased costs ($3,575 vs $1,836) and higher QALYs (0.948 vs 0.925) compared with delayed sling lysis. This translated to early sling loosening being the most cost-effective strategy, with an incremental cost-effectiveness ratio of $74,382/QALY. The model was sensitive to multiple variables on our 1-way sensitivity analysis. For example, delayed sling lysis became cost-effective if the rate of voiding dysfunction resolution with conservative management was greater than or equal to 57% or recurrent stress urinary incontinence after early loosening was greater than or equal to 9.6%. At a willingness-to-pay threshold of 100,000/QALY, early sling loosening was cost-effective in 82% of microsimulations in probabilistic sensitivity analysis.Early sling loosening represents a more cost-effective management method in resolving ongoing voiding dysfunction after sling placement. These findings may favor early clinical management in patients with voiding dysfunction after midurethral sling placement.

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.

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.

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 To report rates and identify risk factors for urinary tract infection (UTI) after hysterectomy for benign conditions or combined with pelvic reconstructive surgery. Methods This is a cohort study that included women who underwent hysterectomy either for benign gynecologic conditions or hysterectomy combined with pelvic reconstructive surgery from January 1, 2012, through June 30, 2014, at a single institution. The primary outcome was UTI within 8 weeks of surgery. Logistic regression modeling was used to develop a model for predicting UTI after surgery. Results Of 1,156 women included in the study, 136 (11.8%, 95% CI 10.0-13.8) developed UTI within 8 weeks. Women who underwent hysterectomy for a benign gynecologic condition that was not combined with pelvic reconstructive surgery had an overall UTI rate of 7.3% (95% CI 5.6-9.3) vs 21.7% (95% CI 17.6-26.4) after hysterectomy combined with pelvic reconstructive surgery. After adjusting for hormone therapy use, the following were independent variables associated with postoperative UTI: premenopausal status with an adjusted odds ratio (OR) of 1.80 (95% CI 1.11-2.99), anterior vaginal wall prolapse with an adjusted OR of 4.39 (95% CI 2.77-6.97), and postvoid residual greater than 150 mL with an adjusted OR of 2.38 (95% CI 1.12-4.36). Using this model, postoperative UTI rates ranged from 4.3% to 59.4% with high postvoid residual and presence of anterior prolapse having the strongest association. Conclusion There are wide variations in the rate of UTI after hysterectomy for begin disease including pelvic reconstructive surgery. These variations can be explained with a model based on available preoperative data.

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.

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 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age 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.

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.

Study Objective The objectives of this study were to (1) pilot a robotic console configuration methodology to optimize ergonomic posture, and (2) determine the effect of this intervention on surgeon posture and musculoskeletal discomfort. Design This was an institutional review board–approved prospective cohort study conducted from February 2017 to October 2017. Setting A single tertiary care midwestern academic medical center. Participants Six fellowship-trained gynecologic surgeons, proficient in robotic hysterectomy, were recruited: 3 men and 3 women. Interventions Each surgeon performed 3 robotic hysterectomies using their self-selected robotic console settings (preintervention). Then, a robotic console ergonomic intervention protocol was implemented by trained ergonomists to improve posture and decrease time in poor ergonomic positions. Each surgeon then performed 3 robotic hysterectomies using the ergonomic intervention settings (postintervention). All surgeries used the da Vinci Xi surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) and were the first case of the day. The surgeons wore inertial measurement unit (IMU) sensors on their head, chest, and bilateral upper arms during surgery. The IMU sensors are equipped with accelerometers, gyroscopes, and magnetometers to give objective measurements of body posture. IMU data were then analyzed to determine the percentage of time spent in ergonomically risky postures as categorized using a modified rapid upper limb assessment. Before and after each hysterectomy, the surgeons completed identical questionnaires for an assessment of musculoskeletal pain/discomfort. The outcome measurements were compared pre- versus postintervention on the basis of fitting generalized linear mixed models that handled the individual surgeon as a random effect and “setting” as a fixed effect. Measurements and Main Results With regard to the IMU posture results, there was a significant decrease in time spent in the moderate- to high-risk neck position and a decrease in average neck angle after the ergonomic intervention. The average percentage of time spent in moderate- to high-risk categories was significantly lower for the neck (mean, 54.3% vs 21.0%; p = .008) and right upper arm (mean, 15.5% vs 0.9%; p = .02) when using the intervention settings compared with the surgeons’ settings. Pain score results: There were fewer reported increases in neck (4 [22%] vs 1 [6%]) and right shoulder (4 [22%] vs 2 [11%]) pain or discomfort after completion of robotic hysterectomy postintervention versus preintervention; however, these differences did not attain statistical significance (p = .12 and p = .37, respectively). Conclusion An ergonomic robotic console intervention demonstrated effectiveness and improved objective surgeon posture at the console when compared with the surgeons’ self-selected settings.

A wide variety of fistulae occur in the female pelvis, most of which cause significant morbidity. Diagnosis, characterization, and treatment planning may be difficult using traditional imaging modalities such as fluoroscopy and computed tomography. To date, there is no comprehensive literature review of the radiologic findings associated with various types of female pelvic fistulae, and furthermore, none dedicated to magnetic resonance imaging (MRI). In this article, we seek to provide a broad overview of the MRI characteristics of female pelvic fistulizing disease in combination with epidemiologic and clinical characteristics. MRI is often considered the imaging modality of choice for evaluation of fistulae owing to its superior soft-tissue contrast and ability to provide surgeons with the highest quality information derived from just one study, including anatomic location of fistulae and associated pelvic pathology. In other instances, MRI can be complementary to the more traditional imaging techniques. This review will describe the etiology, anatomy, MRI findings, and treatment pearls for several of the more common pelvic fistulae found in female patients, including anovaginal, rectovaginal, colovaginal, vesicovaginal, colovesical, and other complex fistulae. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1172-1184.

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.

Study Objective To compare outcomes of vaginal hysterectomy (VH) and robotic-assisted hysterectomy (RH) among women with conditions perceived as contraindications to VH (uterine size ≥ 12 weeks' gestation, no vaginal parity, prior cesarean delivery, and obesity). Design Retrospective chart review (Canadian Task Force classification II-2). Setting Tertiary US medical center. Patients Women with VH or RH. Women with conditions perceived as contraindications affecting surgical choice were excluded. Interventions VH or RH for benign uterine disease at our institution during 2009 through 2013. Measurements and Main Results Among women with the perceived contraindications, a logistic regression model was fit to compare each binary outcome between VH and RH. Models were weighted using inverse probability of treatment weights derived from propensity scores to adjust for covariate imbalance between procedures. The cohort had 692 VHs and 472 RHs. Among 160 women with uterine size ≥ 12 weeks' gestation, RH patients were less likely to have uterine debulking (adjusted odds ratio [aOR], .37; 95% confidence interval [CI], .15–.95]) than VH patients and more likely to have accordion grade ≥ 2 postoperative complications (aOR, 7.20; 95% CI, 1.46–35.42) and readmission (aOR, 15.55; 95% CI. .85–285.20). Among 272 women with prior cesarean section, RH patients were more likely to have grade ≥ 2 postoperative complications (aOR, 2.85; 95% CI, 1.29–6.30). No outcomes were significantly different between surgical routes among women with no vaginal parity or obesity. Mean operative time was significantly longer for RH. Conclusion VH is a surgical option for patients with the conditions perceived as contraindications for vaginal surgery evaluated herein.

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.

Objective To describe the unique presentation and surgical management of a complete uterovaginal septum. Design Video case report. Setting Tertiary care academic medical center. Patient(s) A 25-year-old woman, gravida 2, para 0-0-2-0, referred for evaluation after imaging and clinical examination revealed conflicting information. She was initially seen by her local provider for menorrhagia. Locally an ultrasound revealed a septate uterus, and examination under anesthesia with hysteroscopy noted a single vagina and cervix with a unicornuate uterus. Due to incongruous findings, she was referred for evaluation. Intervention(s) Magnetic resonance imaging (MRI), examination under anesthesia, vaginal surgery, and operative hysteroscopy. Main Outcomes and Measure(s) The MRI identified a complete uterovaginal septum with a single septate cervix. Vaginal gel was used to define vaginal anatomy, and the gel was noted to fill the right hemivagina with none noted on the left. Examination under anesthesia revealed an imperforate hymen with a small opening on the left as the cause for confusion in the clinical presentation. A hymenectomy was performed followed by guided surgical management of a complete uterovaginal septum, unicollis. Result(s) The patient was discharged home the same day of surgery. Conclusion(s) Presentation of mullerian anomalies are often complex, and anatomic variations in commonly described anomalies make misdiagnoses common. Advanced imaging with use of MRI with vaginal gel or three-dimensional ultrasonography and detailed examination are often helpful. Differentiating between unicollis and bicollis presentations in complete uterovaginal septum cases is an important distinction during surgical management.

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

To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy.A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated.Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years.When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Objective To evaluate the rate of vaginal hysterectomy and outcomes after initiation of a prospective decision-tree algorithm to determine the optimal surgical route of hysterectomy. Methods A prospective algorithm to determine optimal route of hysterectomy was developed, which uses the following factors: history of laparotomy, uterine size, and vaginal access. The algorithm was implemented at our institution from November 24, 2015, to December 31, 2017, for patients requiring hysterectomy for benign indications. Expected route of hysterectomy was assigned by the algorithm and was compared with the actual route performed to identify compliance compared with deviation. Surgical outcomes were analyzed. Results Of 365 patients who met inclusion criteria, 202 (55.3%) were expected to have a total vaginal hysterectomy, 57 (15.6%) were expected to have an examination under anesthesia followed by total vaginal hysterectomy, 52 (14.2%) were expected to have an examination under anesthesia followed by robotic-assisted total laparoscopic hysterectomy, and 54 (14.8%) were expected to have an abdominal or robotic-laparoscopic route of hysterectomy. Forty-six procedures (12.6%) deviated from the algorithm to a more invasive route (44 robotic, two abdominal). Seven patients had total vaginal hysterectomy when robotic-assisted total laparoscopic hysterectomy or abdominal hysterectomy was expected by the algorithm. Overall, 71% of patients were expected to have a vaginal route of hysterectomy per the algorithm, of whom 81.5% had a total vaginal hysterectomy performed; more than 99% of the total vaginal hysterectomies attempted were successfully completed. Conclusion Vaginal surgery is feasible, carries a low complication rate with excellent outcomes, and should have a place in gynecologic surgery. National use of this prospective algorithm may increase the rate of total vaginal hysterectomy and decrease health care costs.

Video Objective To present the technical considerations and pearls to performing a LeFort Colpocleisis. Setting Patient is a 76 year old female with history of a vaginal bulge for the past 6 months and a failed pessary trial. She also reports urge-predominant mixed urinary incontinence with worsening stress urinary incontinence with reduction of the pelvic organ prolapse. She is not sexually active and does not plan on any future sexual activity. She does not have any abnormal pap smears and denies postmenopausal bleeding. Her past medical history is significant for multiple comorbid conditions including cardiac issues with a pacemaker, chronic kidney disease, hypertension and diabetes. Her past surgical history is complicated by aortic valve replacement (porcine valve), tubal ligation and a left total knee replacement. On exam she has a Stage IV uterine, anterior and posterior compartment prolapse with positive occult stress urinary incontinence. Urodynamic studies reveal stress urinary incontinence, no detrusor overactivity and an elevated post void residual (125 ml after 241 ml void). She was counseled regarding management options including conservative options (observation or repeat pessary trial), restorative procedures (vaginal vault suspension or sacrocolpopexy), or an obliterative procedure such as a LeFort Colpocleisis. Interventions The patient opted for a LeFort Colpocleisis. She underwent a Dilation and curettage, a LeFort colpocleisis, Posterior colpoperineorrhaphy, Cystoscopy and a Midurethral Sling Placement. Conclusion The technical considerations for performing a LeFort Colpocleisis include ruling out malignancy prior to surgery, adequate lateral channels for uterine drainage, the use of lidocaine with epinephrine, closure in multiple layers with excellent hemostasis and an aggressive posterior colpoperineorrhaphy.

Objective To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures. Methods We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure. Results We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups. Conclusion Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.

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.

Nationally, there is increasing concern regarding the volume of opioid medications prescribed postoperatively and the rate of prescription opioid-related adverse events. In evaluation of this, several reports have identified significant variability in postoperative opioid-prescribing patterns, including quantities exceeding patient's needs, especially after minor surgical procedures. However, data regarding patient's postoperative opioids needs following surgery for pelvic organ prolapse are sparse.To design procedure-specific opioid-prescribing recommendations for pelvic organ prolapse surgeries and evaluate their impact on opioid stewardship.We prospectively evaluated opioid-prescribing patterns, patient use, medication refills, and patient satisfaction in women undergoing prolapse surgery (ie, vaginal, abdominal, or robotic) during an 8-month time period. Two cohorts of women, stratified by whether they had surgery before or after implementation of procedure-specific opioid-prescribing recommendations, were evaluated. Postoperative opioid usage (assessed via pill count), medication refills, and satisfaction with pain management after hospital dismissal were evaluated by telephone call 2 weeks after surgery. Postoperative opioid prescribing and use were recorded after conversion to oral morphine equivalents.Overall, 96 women were included, 57 in the initial baseline cohort, and 39 following implementation of the prescribing recommendations. In the initial cohort, 32.8% of the prescribed oral morphine equivalents (3607/11,007 mg) were consumed. Following implementation of the prescribing recommendations, median oral morphine equivalents prescribed decreased from 200 mg oral morphine equivalents (interquartile range 150, 225) to 112.5 mg oral morphine equivalents (interquartile range 22.5, 112.5; P.0001). The total oral morphine equivalents prescribed decreased by 45% when compared with the volume that would have been prescribed before implementing the recommendations. The amount of leftover opioids per patient significantly decreased as well (P.0001). Pain medication refills increased after the intervention (18% vs 3.5%; P=.03), whereas satisfaction scores were similar in both cohorts (P=.87).By using procedure-specific opioid prescribing recommendations, we decreased the number of opioids prescribed at hospital dismissal by roughly one half. Decreased opioid prescribing did not adversely impact patient satisfaction.

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.

Study Objective To describe the unique presentation and surgical management of a complete utero-vaginal septum. Design Video case report. Setting Tertiary care academic medical center. Patients or Participants We present a 25-year-old G2P0020 who is referred for evaluation after imaging and clinical examination revealed conflicting information. She was initially seen by her local provider for menorrhagia. Locally, an ultrasound revealed a septate uterus and examination under anesthesia with hysteroscopy noted a single vagina and cervix with a unicornuate uterus. Due to incongruous findings, she was referred for evaluation. Interventions Magnetic resonance imaging (MRI), examination under anesthesia, vaginal surgery and operative hysteroscopy. Measurements and Main Results MRI identified a complete utero-vaginal septum with a single septate cervix. Vaginal gel was used to define vaginal anatomy and gel was noted to fill the right hemivagina, while none noted on the left. Examination under anesthesia revealed an imperforate hymen with a small opening on the left as the cause for confusion in the clinical presentation. A hymenectomy was performed followed by guided surgical management of a complete utero-vaginal septum, unicollis. Conclusion Presentation of mullerian anomalies are often complex and anatomic variations in commonly described anomalies make misdiagnoses common. Advanced imaging with use of MRI with vaginal gel or 3-dimensional ultrasonography and detailed examination are often helpful. Differentiating between unicollis and bicollis presentations in complete utero-vaginal septum cases is an important distinction during surgical management.

OBJECTIVE To compare efficacy and safety of retropubic Burch urethropexy and a midurethral sling in women with stress urinary incontinence (SUI) undergoing concomitant pelvic floor repair with sacrocolpopexy. METHODS Women were randomly assigned to Burch retropubic urethropexy (n=56) or retropubic midurethral sling (n=57) through dynamic allocation balancing age, body mass index, history of prior incontinence surgery, intrinsic sphincter deficiency, preoperative incontinence diagnosis, and prolapse stage. Overall and stress-specific continence primary outcomes were ascertained with validated questionnaires and a blinded cough stress test. RESULTS Enrollment was June 1, 2009, through August 31, 2013. At 6 months, no difference was found in overall (29 midurethral sling [51%] compared with 23 Burch [41%]; P=.30) (odds ratio [OR] 1.49, 95% confidence interval [CI] 0.71-3.13) or stress-specific continence rates (42 midurethral sling [74%] compared with 32 Burch [57%]; P=.06) (OR 2.10, 95% CI 0.95-4.64) between groups. However, the midurethral sling group reported greater satisfaction (78% compared with 57%; P=.04) and were more likely to report successful surgery for SUI (71% compared with 50%; P=.04) and to resolve pre-existing urgency incontinence (72% compared with 41%; P=.03). No difference was found in patient global impression of severity or symptom improvement, complication rates, or mesh exposures. CONCLUSION There was no difference in overall or stress-specific continence rates between midurethral sling and Burch urethropexy groups at 6 months. However, the midurethral sling group reported better patient-centered secondary outcomes.

As minimally invasive technology continues to be developed and refined, surgeons must be discerning in choosing the safest, cost-effective surgical approach associated with the best outcomes for each individual patient. Vaginal hysterectomy can be successfully accomplished even in challenging situations, such as previous pelvic surgery, nulliparity, uterine enlargement, or obesity. Vaginal hysterectomy should be considered the primary route for treatment of benign disease.

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.