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9: Thrombosed postpartum urethral prolapse
Videofests
9
Thrombosed postpartum urethral prolapse
K. Elmezzi, H. Matthews, G. Stone, J. Fischer, D. Gruber Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD
OBJECTIVE: Urethral prolapse is a rare occurrence with a reported incidence of approximately 1:3000. Although its etiology is unclear, proposed causes include lack of estrogen and dysfunctional periurethral tissue. Few reports have been described in reproductive age women, with most affected being in the pre-pubertal and postmenopausal period. DESCRIPTION: This is a video of a 29-year-old woman who presented to the Urogynecology clinic five weeks after an uncomplicated vaginal delivery with a painful peri-urethral mass consistent with thrombosis of the prolapsed urethral tissue. Initial conservative management with an indwelling urethral catheter and topical estrogen did not relieve her symptoms. This video shows the surgical technique used to excise the thrombosed tissue in the operating room. The procedure was uncomplicated and at postoperative follow-up, she reported complete resolution of her symptoms. CONCLUSION: Patients with urethral prolapse most commonly present with vaginal bleeding and lower urinary tract symptoms. In contrast, this patient likely suffered trauma to the urethra during vaginal delivery, resulting in thrombosis. The usual conservative treatments for urethral prolapse were ineffective and she underwent surgical management with complete resolution of her symptoms. Urethral thrombosis should be considered when evaluating premenopausal women with a painful peri-urethral mass. Treatment should be tailored to the patient and surgical excision considered after failure of conservative management.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Kristen Elmezzi: Nothing to disclose; Horace Matthews: Nothing to disclose; George Stone: Nothing to disclose; John Fischer: Nothing to disclose; Daniel Gruber: Nothing to disclose.
10 The role of preoperative imaging in guiding laparoscopic excision of deep endometriosis M. S. Abrao, L. Myung, L. C. Fernandes, M. Goncalves, L. Accardo, M. Bassi Obstetrics and Gynecology, Sao Paulo University, Sao Paulo, Sao Paulo, Brazil
OBJECTIVE: To show the preoperative imaging strategies guiding the operative management of deep endometriosis compromising the retrocervical region, the vagina, the bowel, the ureters, the nerves and the bladder based on a case of a patient with multifocal lesions. DESCRIPTION: We present the case of a 26-year-old woman with severe dysmenorrhea, cyclic dyschezia, and dysuria since 14-year-old, gynecological examination revealed fibrotic nodule in the rectovaginal septum. Ultrasound with bowel preparation (rectal enema one hour before the examination) and nuclear magnetic resonance suggested deep endometriosis lesions on left pararectal region toward the pelvic floor infiltrating the inferior hypogastric plexus and near the sacral roots; retrocervical lesion with more than 3 cm; lesion on the posterior vaginal fornix measuring 3.5 0.7 2.3 cm; bladder endometriosis with 1.7 1.2 1.6 cm with detrusor muscle infiltration and a rectosigmoid lesion with 3.5 1.0 1.8 cm.
ajog.org
Laparoscopy was performed guided by pre-operative imaging examinations. Opening of the retroperitoneum and the mesosigmoid followed by the identification of the ureters and the left inferior hypogastric plexus. Rectosigmoidectomy using linear staple ring applied on distal area affected by the disease, excision of lesion exteriorizing the divided bowel, the circular stapler is then introduced through the anus and connected to the ogive, and the stapler is activated to form the end to end anastomosis. Vagina and bladder lesion are excised and repaired with suture. CONCLUSION: Preoperative imaging examinations consist on a great strategy to completely remove and treat the disease. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Mauricio S. Abrao: Nothing to disclose; Lidia Myung: Nothing to disclose; luiz F. C. Fernandes: Nothing to disclose; Manoel Goncalves: Nothing to disclose; Leandro Accardo: Nothing to disclose; Marco Antonio Bassi: Nothing to disclose.
11 Uterosacral ligament suspension after failed sacrocolpopexy complicated by vaginal mesh exposure M. Moen, K. Jirschele, B. Vassallo, M. Noone Illinois Urogynecology, Park Ridge, IL
OBJECTIVE: To demonstrate a vaginal approach for surgical management of recurrent prolapse complicated by vaginal mesh exposure. DESCRIPTION: This video demonstrates key steps in performing a vaginal approach for surgical management of recurrent prolapse and mesh exposure. These steps include identification of anatomical landmarks; peritoneal entry; lysis of adhesions; dissection of previously placed mesh from associated structures including bowel; and placement of culdoplasty and uterosacral suspension sutures. CONCLUSION: Prolapse recurrence and mesh exposure can occur after surgery utilizing mesh for repair of pelvic organ prolapse such as sacrocolpopexy and vaginal mesh procedures. A vaginal approach can be utilized to address mesh exposure and perform uterosacral ligament suspension for treatment of recurrent prolapse in these cases.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Michael Moen: Nothing to disclose; Kelly Jirschele: Nothing to disclose; Brett Vassallo: Nothing to disclose; Michael Noone: Nothing to disclose.
12 Strategies to overcome the loss of port placement triangulation A. A. Adajar1, S. McCarus2, L. McCauley3 1 Obstetrics and Gynecology, Illinois Institute of Gynecology & Advanced Pelvic Surgery, Chicago, IL, 2Division of GYN Surgery, Florida Hospital Celebration Health, Celebration, FL, 3Obstetrics and Gynecology, Physician’s Regional Medical Center, Knoxville, TN
OBJECTIVE: This video demonstrates several techniques to overcome the challenges that arise from the loss of port placement triangulation. DESCRIPTION: When clinical circumstances exist, making the vaginal approach less feasible, effort to limit incisions to the umbilicus has cosmetic benefits. A midline umbilical approach creates several
S622 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017
9
Thrombosed postpartum urethral prolapse
K. Elmezzi, H. Matthews, G. Stone, J. Fischer, D. Gruber Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD
OBJECTIVE: Urethral prolapse is a rare occurrence with a reported incidence of approximately 1:3000. Although its etiology is unclear, proposed causes include lack of estrogen and dysfunctional periurethral tissue. Few reports have been described in reproductive age women, with most affected being in the pre-pubertal and postmenopausal period. DESCRIPTION: This is a video of a 29-year-old woman who presented to the Urogynecology clinic five weeks after an uncomplicated vaginal delivery with a painful peri-urethral mass consistent with thrombosis of the prolapsed urethral tissue. Initial conservative management with an indwelling urethral catheter and topical estrogen did not relieve her symptoms. This video shows the surgical technique used to excise the thrombosed tissue in the operating room. The procedure was uncomplicated and at postoperative follow-up, she reported complete resolution of her symptoms. CONCLUSION: Patients with urethral prolapse most commonly present with vaginal bleeding and lower urinary tract symptoms. In contrast, this patient likely suffered trauma to the urethra during vaginal delivery, resulting in thrombosis. The usual conservative treatments for urethral prolapse were ineffective and she underwent surgical management with complete resolution of her symptoms. Urethral thrombosis should be considered when evaluating premenopausal women with a painful peri-urethral mass. Treatment should be tailored to the patient and surgical excision considered after failure of conservative management.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Kristen Elmezzi: Nothing to disclose; Horace Matthews: Nothing to disclose; George Stone: Nothing to disclose; John Fischer: Nothing to disclose; Daniel Gruber: Nothing to disclose.
10 The role of preoperative imaging in guiding laparoscopic excision of deep endometriosis M. S. Abrao, L. Myung, L. C. Fernandes, M. Goncalves, L. Accardo, M. Bassi Obstetrics and Gynecology, Sao Paulo University, Sao Paulo, Sao Paulo, Brazil
OBJECTIVE: To show the preoperative imaging strategies guiding the operative management of deep endometriosis compromising the retrocervical region, the vagina, the bowel, the ureters, the nerves and the bladder based on a case of a patient with multifocal lesions. DESCRIPTION: We present the case of a 26-year-old woman with severe dysmenorrhea, cyclic dyschezia, and dysuria since 14-year-old, gynecological examination revealed fibrotic nodule in the rectovaginal septum. Ultrasound with bowel preparation (rectal enema one hour before the examination) and nuclear magnetic resonance suggested deep endometriosis lesions on left pararectal region toward the pelvic floor infiltrating the inferior hypogastric plexus and near the sacral roots; retrocervical lesion with more than 3 cm; lesion on the posterior vaginal fornix measuring 3.5 0.7 2.3 cm; bladder endometriosis with 1.7 1.2 1.6 cm with detrusor muscle infiltration and a rectosigmoid lesion with 3.5 1.0 1.8 cm.
ajog.org
Laparoscopy was performed guided by pre-operative imaging examinations. Opening of the retroperitoneum and the mesosigmoid followed by the identification of the ureters and the left inferior hypogastric plexus. Rectosigmoidectomy using linear staple ring applied on distal area affected by the disease, excision of lesion exteriorizing the divided bowel, the circular stapler is then introduced through the anus and connected to the ogive, and the stapler is activated to form the end to end anastomosis. Vagina and bladder lesion are excised and repaired with suture. CONCLUSION: Preoperative imaging examinations consist on a great strategy to completely remove and treat the disease. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Mauricio S. Abrao: Nothing to disclose; Lidia Myung: Nothing to disclose; luiz F. C. Fernandes: Nothing to disclose; Manoel Goncalves: Nothing to disclose; Leandro Accardo: Nothing to disclose; Marco Antonio Bassi: Nothing to disclose.
11 Uterosacral ligament suspension after failed sacrocolpopexy complicated by vaginal mesh exposure M. Moen, K. Jirschele, B. Vassallo, M. Noone Illinois Urogynecology, Park Ridge, IL
OBJECTIVE: To demonstrate a vaginal approach for surgical management of recurrent prolapse complicated by vaginal mesh exposure. DESCRIPTION: This video demonstrates key steps in performing a vaginal approach for surgical management of recurrent prolapse and mesh exposure. These steps include identification of anatomical landmarks; peritoneal entry; lysis of adhesions; dissection of previously placed mesh from associated structures including bowel; and placement of culdoplasty and uterosacral suspension sutures. CONCLUSION: Prolapse recurrence and mesh exposure can occur after surgery utilizing mesh for repair of pelvic organ prolapse such as sacrocolpopexy and vaginal mesh procedures. A vaginal approach can be utilized to address mesh exposure and perform uterosacral ligament suspension for treatment of recurrent prolapse in these cases.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Michael Moen: Nothing to disclose; Kelly Jirschele: Nothing to disclose; Brett Vassallo: Nothing to disclose; Michael Noone: Nothing to disclose.
12 Strategies to overcome the loss of port placement triangulation A. A. Adajar1, S. McCarus2, L. McCauley3 1 Obstetrics and Gynecology, Illinois Institute of Gynecology & Advanced Pelvic Surgery, Chicago, IL, 2Division of GYN Surgery, Florida Hospital Celebration Health, Celebration, FL, 3Obstetrics and Gynecology, Physician’s Regional Medical Center, Knoxville, TN
OBJECTIVE: This video demonstrates several techniques to overcome the challenges that arise from the loss of port placement triangulation. DESCRIPTION: When clinical circumstances exist, making the vaginal approach less feasible, effort to limit incisions to the umbilicus has cosmetic benefits. A midline umbilical approach creates several
S622 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017