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Laparoscopic Stripping of Diaphragm after Chemotherapy in Advanced Ovarian Cancer
Abstracts / Journal of Minimally Invasive Gynecology 19 (2012) S1–S35 functioning. Additional calls to the women were made 4, 7 and 14 days and 4, 6, 8 and 12 weeks after surgery to obtain updates on the women’s pain, well-being and procedure satisfaction. Information on the surgical procedure was collected from the participants’ medical charts. There were 245 women recruited; 17 vaginal hysterectomies were excluded. Hierarchical generalized linear models were used to model the trajectory of pain, well-being and satisfaction over the course of the post-surgical period. Pain and satisfaction were modeled as dichotomous (any pain versus none; completely satisfied versus not). Well-being was analyzed as continuous (0-10). Of the 228 women included in the analyses, 156 (68.4%) had their cervix removed. Cervix removal was not associated with reported satisfaction (p = 0.55) or well-being (p = 0.44). Even after adjusting for whether the surgery was ‘‘open’’ and baseline scores. Women who had cervix removal were more likely to report having pain after surgery (aOR = 1.80, 95% CI 1.05, 3.08) after adjusting for their baseline score. The association weakened marginally after adjusting for surgical approach (aOR = 1.68, 95% CI 0.97, 2.90). Cervix removal was not associated with pain/discomfort with penetration during sex, (OR = 0.69; 95% CI 0.27, 1.79). Conclusion: In hysterectomy patients, cervix removal was not associated with adverse reporting of well-being or satisfaction after surgery but was weakly associated with reporting pain.
98
Open Communications 7dUrogynecology (3:03 PM d 3:08 PM)
Interest of the 3D Ultrasound Evaluation of Suburethral Tape after TVT-O Procedure Legendre G, Levaillant J-M, Moulin J, Fernandez H. Department of Obstetrics and Gynaecology, H^opital Bic^etre - Assistance Publique des H^ opitaux de Paris, Le Kremlin Bic^etre, Ile de France, France Study Objective: To define the place of 3D ultrasound in the postoperative evaluation of suburethral tapes after TVT-O procedure. Design: Prospective study of 32 consecutive cases of TVT-O procedure for stress urinary incontinence (SUI) from May 2010 to December 2011. Setting: Gynecology department in a teaching hospital. Patients: Thirty-two consecutive patients with TVT-O procedures for SUI and 3D ultrasound. Intervention: All TVT-O procedures used the Gynecare TVT Obturator system. TVT-O procedure was performed according to manufacturers’ recommendations. A 3D ultrasound examination was performed between 6 and 9 weeks after the TVT-O procedure. The position of the tape was determined in reference to the bladder neck (uretro-vesical junction) on a sagittal section plan. The spreading of the tape was assessing in the 3 dimensions (axial, sagittal and coronal). Clinical findings were evaluated after the 3D ultrasound, subjectively and objectively by using validated questionnaires. Measurements and Main Results: 3D ultrasound was available for each patient. Global cure rate for stress urinary incontinence was 94.1 %. Mean distance between the tape and the urethro-vesical junction was 13.1 mm (2.8-20 mm). For 27 patients (84.3%) the sub-urethral tape seem to be well spread and well placed. For four patients (9 %), a post-operative over-active bladder was noted. In three of these four patients, the tape was founded to be too close to the bladder neck (less than 2.8, 6 and 7.7 mm respectively). A short distance between the tape and the bladder neck was statistically associated with a post-operative over active bladder (p = 0.006). In one patient, a complete median twist of the tape was noted on sagittal section plan and was associated with dyspareunia and over active bladder syndrome. In one patient a lateral twist was found without any symptoms reported. Conclusion: 3D ultrasound seems to be a good exam to evaluate the good positioning of the tape and to predict postoperative overactive bladder syndrome.
99
S35
Open Communications 7dUrogynecology (3:09 PM d 3:14 PM)
An Unusual Case of Mesh Erosion Following Laparoscopic Sacrocervicopexy Moulder JK, Cohen SL, Einarsson JI. Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts Study Objective: To present a unique case of mesh complication following laparoscopic sacrocervicopexy and discuss the prevalence of mesh erosion in laparoscopic procedures performed for pelvic organ prolapse. Design: Case Report. Setting: Major Academic Center. Patients: 55yo G3P2012 presents with vaginal discharge 10 months following an uncomplicated laparoscopic supracervical hysterectomy and sacrocervicopexy with anterior and posterior colporrhaphy for symptomatic pelvic organ prolapse. She was maintained on vaginal estrogen for atrophy. Multiple examinations of the vagina revealed only grayish discharge without evidence of mesh. Imaging did not reveal a fistula. Vaginoscopy under anesthesia demonstrated mesh at the prior junction of the endocervix and lower uterine segment. Intervention: Patient underwent laparoscopic mesh excision with trachelectomy. Mesh was visualized protruding through internal cervical os. Chronic inflammation was noted around mesh erosion, however no abscess or purulence was appreciated. Uterosacral ligament suspension was performed for reinforced vault suspension. Pathology revealed cervical mucosal ulceration with acute and chronic inflammation, and foreign body giant cell reaction to mesh material. Measurements and Main Results: Erosion is a known complication of procedures using synthetic mesh for pelvic organ or vault suspension. Concurrent hysterectomy with mesh suspension procedure is a risk factor for erosion, however, rates in the literature are higher with total hysterectomy compared to supracervical hysterectomy. Bacterial infection or devascularization of tissue are thought to contribute to erosion risk. The in situ cervix maintains vascularization, is a barrier to vaginal flora and requires less mesh for suspension. In this case, migration of the mesh into the cervical os resulted in chronic inflammation and impaired healing, presenting as vaginal discharge. Conclusion: Despite use of the cervix as an additional barrier, mesh erosion may still occur in patients undergoing laparoscopic sacrocervicopexy. This unusual presentation highlights the importance of vigilance regarding prevention and management of mesh-related events. 100
Video Session 3dOncology (2:15 PM d 2:22 PM)
Laparoscopic Stripping of Diaphragm after Chemotherapy in Advanced Ovarian Cancer Shiki Y,1 Kim Y-K.2 1Obstetrics and Gynecology, Osaka Rosai Hospital, Sakai, Osaka, Japan; 2Surgery, Osaka Rosai Hospital, Sakai, Osaka, Japan Objective: In dissecting diaphragm, wide horizontal incision is usually needed to dislocate liver for laparotomy. After chemotherapy, the process become more difficult because of the fibrosis of disseminated area due to chemo-effect. We examined 7 consecutive patients of ovarian cancer stage 3c between Januray 2009 and December 2011 in Osaka Rosai Hospital. Interventions: Stripping of disseminated diaphragm was first done using laparoscope, the rest of procedures needed for debulking followed by laparotomy. Results: Good visualization was obtained, especially in the deepest part of diaphragm by using laparoscope. Average post-operational hospital stay was 3days in total laparoscope case, 10 days in hand assisted laparoscope group, but it was45 days in laparotomy case, who needed painkiller for more than a month. Accidental thoracotomy was observed in four cases, but it can be managed safely. No metastasis was observed in this area after operation up to now.
98
Open Communications 7dUrogynecology (3:03 PM d 3:08 PM)
Interest of the 3D Ultrasound Evaluation of Suburethral Tape after TVT-O Procedure Legendre G, Levaillant J-M, Moulin J, Fernandez H. Department of Obstetrics and Gynaecology, H^opital Bic^etre - Assistance Publique des H^ opitaux de Paris, Le Kremlin Bic^etre, Ile de France, France Study Objective: To define the place of 3D ultrasound in the postoperative evaluation of suburethral tapes after TVT-O procedure. Design: Prospective study of 32 consecutive cases of TVT-O procedure for stress urinary incontinence (SUI) from May 2010 to December 2011. Setting: Gynecology department in a teaching hospital. Patients: Thirty-two consecutive patients with TVT-O procedures for SUI and 3D ultrasound. Intervention: All TVT-O procedures used the Gynecare TVT Obturator system. TVT-O procedure was performed according to manufacturers’ recommendations. A 3D ultrasound examination was performed between 6 and 9 weeks after the TVT-O procedure. The position of the tape was determined in reference to the bladder neck (uretro-vesical junction) on a sagittal section plan. The spreading of the tape was assessing in the 3 dimensions (axial, sagittal and coronal). Clinical findings were evaluated after the 3D ultrasound, subjectively and objectively by using validated questionnaires. Measurements and Main Results: 3D ultrasound was available for each patient. Global cure rate for stress urinary incontinence was 94.1 %. Mean distance between the tape and the urethro-vesical junction was 13.1 mm (2.8-20 mm). For 27 patients (84.3%) the sub-urethral tape seem to be well spread and well placed. For four patients (9 %), a post-operative over-active bladder was noted. In three of these four patients, the tape was founded to be too close to the bladder neck (less than 2.8, 6 and 7.7 mm respectively). A short distance between the tape and the bladder neck was statistically associated with a post-operative over active bladder (p = 0.006). In one patient, a complete median twist of the tape was noted on sagittal section plan and was associated with dyspareunia and over active bladder syndrome. In one patient a lateral twist was found without any symptoms reported. Conclusion: 3D ultrasound seems to be a good exam to evaluate the good positioning of the tape and to predict postoperative overactive bladder syndrome.
99
S35
Open Communications 7dUrogynecology (3:09 PM d 3:14 PM)
An Unusual Case of Mesh Erosion Following Laparoscopic Sacrocervicopexy Moulder JK, Cohen SL, Einarsson JI. Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts Study Objective: To present a unique case of mesh complication following laparoscopic sacrocervicopexy and discuss the prevalence of mesh erosion in laparoscopic procedures performed for pelvic organ prolapse. Design: Case Report. Setting: Major Academic Center. Patients: 55yo G3P2012 presents with vaginal discharge 10 months following an uncomplicated laparoscopic supracervical hysterectomy and sacrocervicopexy with anterior and posterior colporrhaphy for symptomatic pelvic organ prolapse. She was maintained on vaginal estrogen for atrophy. Multiple examinations of the vagina revealed only grayish discharge without evidence of mesh. Imaging did not reveal a fistula. Vaginoscopy under anesthesia demonstrated mesh at the prior junction of the endocervix and lower uterine segment. Intervention: Patient underwent laparoscopic mesh excision with trachelectomy. Mesh was visualized protruding through internal cervical os. Chronic inflammation was noted around mesh erosion, however no abscess or purulence was appreciated. Uterosacral ligament suspension was performed for reinforced vault suspension. Pathology revealed cervical mucosal ulceration with acute and chronic inflammation, and foreign body giant cell reaction to mesh material. Measurements and Main Results: Erosion is a known complication of procedures using synthetic mesh for pelvic organ or vault suspension. Concurrent hysterectomy with mesh suspension procedure is a risk factor for erosion, however, rates in the literature are higher with total hysterectomy compared to supracervical hysterectomy. Bacterial infection or devascularization of tissue are thought to contribute to erosion risk. The in situ cervix maintains vascularization, is a barrier to vaginal flora and requires less mesh for suspension. In this case, migration of the mesh into the cervical os resulted in chronic inflammation and impaired healing, presenting as vaginal discharge. Conclusion: Despite use of the cervix as an additional barrier, mesh erosion may still occur in patients undergoing laparoscopic sacrocervicopexy. This unusual presentation highlights the importance of vigilance regarding prevention and management of mesh-related events. 100
Video Session 3dOncology (2:15 PM d 2:22 PM)
Laparoscopic Stripping of Diaphragm after Chemotherapy in Advanced Ovarian Cancer Shiki Y,1 Kim Y-K.2 1Obstetrics and Gynecology, Osaka Rosai Hospital, Sakai, Osaka, Japan; 2Surgery, Osaka Rosai Hospital, Sakai, Osaka, Japan Objective: In dissecting diaphragm, wide horizontal incision is usually needed to dislocate liver for laparotomy. After chemotherapy, the process become more difficult because of the fibrosis of disseminated area due to chemo-effect. We examined 7 consecutive patients of ovarian cancer stage 3c between Januray 2009 and December 2011 in Osaka Rosai Hospital. Interventions: Stripping of disseminated diaphragm was first done using laparoscope, the rest of procedures needed for debulking followed by laparotomy. Results: Good visualization was obtained, especially in the deepest part of diaphragm by using laparoscope. Average post-operational hospital stay was 3days in total laparoscope case, 10 days in hand assisted laparoscope group, but it was45 days in laparotomy case, who needed painkiller for more than a month. Accidental thoracotomy was observed in four cases, but it can be managed safely. No metastasis was observed in this area after operation up to now.