- Email: [email protected]
Surgical Management of Complex Uretheral Diverticulum
S178
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Case: We present a case of 32 y.o. female with a large, symptomatic, evolving vaginal wall cyst of unclear etiology. On examination, a cystic mass measuring 6 x 3 cm encompassing the right anterolateral vaginal wall was identified. Cystogram & MRI ruled out any communication between the cyst and the lower urinary tract.
Pathology confirmed a benign mullerian cyst lined with mucinous & squamous epithelium with associated chronic inflammation. The patient remained asymptomatic & is without recurrence. Discussion: This case differs from the norm with the cyst evolving in size & being increasingly symptomatic. Most mullerian cysts are less than 2 cm in diameter. When symptomatic, excision requires the entire cyst wall to be removed to prevent recurrence. The preponderance of vaginal wall cysts are diagnosed clinically as gartners duct cysts; however, the vast majority of cysts are histopathologically found to be of mullerian origin with the cyst wall characteristically lined by mucin producing epithelium in contrast to gartners duct cyst which are non mucin producing.
589 Surgical Management of Complex Uretheral Diverticulum Mama ST, Chaudhry U. Ob/Gyn, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey
The origin was either vaginal or bladder. Surgical excision of the cyst was performed with careful dissection from its attachment to the right lateral vaginal wall & periurethral tissue.
Cystoscopy with right ureteral stent placement was done intra-operatively prior to dissection. The stent was removed at the end of procedure.
Study Objective: Background: Urethral diverticulum is a herniation between the periurethral fibromuscular layer and anterior vaginal wall continuous with the lumen of the urethra. The incidence is 1 to 6%.It occurs commonly in the third to fifth decade of life. The condition can be acquired or congenital. The etiology is not understood. The most widely accepted theory is obstruction and subsequent infection of the periurethral glands with rupture of the abscess into the lumen. Other causes include trauma from vaginal or urethral surgery and childbirth trauma.The diagnosis of urethral diverticulum can be confused with vaginal wall inclusion cysts,mesonephric or paramesonephric cysts, Skene gland cysts, urethral caruncles, and urethroceles. Case: A 52 year old surgically postmenopausal female presented with severe symphysis pubis and vaginal pain with painful urination. The pain preceded and was present during voiding. Physical exam was nonspecific. The patient required combined NSAIDs and narcotics for relief. CT scan and MRI confirmed a large 3 cm diverticulum.
The diverticulum occupied the entire urethral length occupying 270 degrees with the neck at the 8 oclock position. The patient had no risk factors. The diverticulum was dissected out entirely including the neck and excised. The defect in the urethral lumen was closed. Reconstruction of the posterior periurethral fibromuscular layer was done in a pants over vest technique. There were no post operative complications and patient had resolution of her symptoms. Conclusion: The clinical presentation of urethral diverticulum is varied, the diagnosis and management often delayed. Transvaginal excision of urethral diverticulum remains the gold standard. Success depends on determination of the extent and number of diverticula and attention to surgical technique. The recurrence rate is 11%. This case is unusual in
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
S179
583 Modified Technique for the Placement of Sub-Urethral Sling Tension-Free Polypropylene Mesh in Patients with Stress Urinary Incontinence Morgan-Ortiz F, Josefina B-B, Juan. Manuel S-P. Centro de Investigacion y Docencia en Ciencias de la Salud, Universidad Autonoma de Sinaloa, Hospital Civil de Culiacan, Culiacan, Sinaloa, Mexico
having no risk factors, sudden onset and the extent and size of the diverticulum.
590 Surgical Outcomes in the Use of Porcine Small Intestine Submucosal Graft (Cook Medical Biodesign Surgisis Posterior Pelvic Floor Graft) for Vaginal Repair of Pelvic Organ Prolapse Masone M, Jarnagin BK, Tatalovich JM, Ritch JMB. Center of Pelvic Health, Franklin, Tennessee Study Objective: To describe the use of porcine small intestine submucosal graft to aid in the vaginal prolapse repair with sacrospinous ligament suspensions in patients declining mesh and to report on preliminary outcomes. Design: Retrospective analysis on 19 consecutive cases of vaginal prolapse repair cases using graft. Setting: Hospital based private urogynecology practice. Patients: 19 women with pelvic organ prolapse. Intervention: Vaginal repair of pelvic organ prolapse using the Surgisis posterior pelvic floor graft. The graft arms were attached to the sacrospinous ligament utilizing an anchoring device. The body of the graft was attached to the vagina and the arms secured to the sacrospinous ligament bilaterally supporting the entire vagina. Measurements and Main Results: The 19 patients had an average age of 62 years (SD 11) and average BMI of 29.2 (SD 5.6). The mode preoperative pelvic organ prolapse quantification (POP-Q) stage was 2 (range 2-4). Of the 16 patients with a POPQ stage recorded at their 6 weeks post-operative visit, 12 patients were POPQ stage 0, 1 was POPQ stage 1 and 3 were POPQ stage 2. The mode change in stage was 2 (range 1-4). Two patients did not show for the 6 week post-operative visit. Of the 15 patients with follow-up at 3 months, 9 maintained their initial post-operative POPQ stage 0, two maintained their initial postoperative POPQ stage 2, and one patient increased from postoperative stage 1 to stage 2. Of the 3 patients with follow-up at 6 months, one maintained the 3 month POPQ stage 0 and two had increased. One patient increased from stage 2 to stage 3 at 6 months and one patient increased from stage 0 to stage 2 at 6 months. Conclusion: Preliminary data of the vaginal use of porcine graft shows that it is effective at reducing pelvic organ prolapse. Further study is needed to determine long-term efficacy and recurrence rates.
Study Objective: To describe the results of a modified technique for the placement of sub-urethral sling with polypropylene mesh in patients with stress urinary incontinence. Design: Prospective analysis of 62 cases of stress urinary incontinence undergoing anti-incontinence surgery and were followed from January 2005 to December 2010 at Hospital Civil de Culiacan, Sinaloa, Mexico. Setting: Public teaching hospital at Culiacan, Sinaloa, Mexico. Patients: Sixty two patients with stress urinary incontinence. Intervention: Modified technique using of Pereyra needle for placement of the sub-urethral sling with polypropilene mesh. This technique is a modification of the original technique of TVT (Gynecare TVTTM, Ethicon Women’s Health & Urology Ethicon, Inc.) Johnson & Johnson Company, Somerville, New Jersey, USA) which was replaced by a monofilament polypropylene mesh (25 x 25 cm, SPMLI, PROLENE Soft Polypropylene Mesh, Ethicon, Inc.) Johnson & Johnson Company, Somerville, New Jersey, USA). This mesh was cut in pieces of 1,5 cm wide by 8 cm long (Off label use) and placed underneath the mid-urethra with the aid of needle Pereyra. Measurements and Main Results: The cumulative cure rate at 12, 24, 36, 48 and 60 months were 96,7% (n = 60), 91,9% (n= 57), 90,3% 8n = 56), 90,3% (n = 56) and 85,5% (n= 53) respectively. The mean length of the procedure was 35,7 minutes (SD:14,2). The mean intraoperative bleeding was 138,7 ml (SD: 88.2.) (R: 50 ml to 200 ml). The frequency of complications were: residual cystocele (3.2%), extrusion of material through vaginal mucosa in three cases (4.8%). There were no cases of bladder injury, bowel injury, urinary retention or bladder erosion. Conclusion: The placement of the tension-free sub-urethral sling with modified technique using the Pereyra needle is a feasible and safe treatment option for patients with stress urinary incontinence, with similar cure rates and less morbidity than that reported in the literature with the original TVT.
591 Outcomes of Total Robotic Hysterectomy Versus Supracervical Hysterectomy with Sacrocolpopexy for Uterovaginal Prolapse at One Year Myers EM,1 Siff L,2 Osmundsen B,3 Geller EJ,1 Matthews CA.1 1Female Pelvic Medicine and Reconstructive Surgery/OBGYN, university of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 2Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts; 3Obstetrics and Gynecology, Providence Medical Center, Portland, Oregon Study Objective: To determine if there is a difference in recurrent pelvic organ prolapse (POP), defined as > Stage II by the Pelvic Organ Prolapse Quantification system (POP-Q), at one year after undergoing total robotic hysterectomy (TRH) versus supracervical robotic hysterectomy (SRH) at the time of robotic sacrocolpopexy (RSCP) for uterovaginal prolapse. Design: Retrospective cohort analysis. Setting: University of North Carolina Hospital and Providence Medical Center. Patients: One hundred and nine women who underwent hysterectomy with RSCP over a 24-month period were identified, five declined participation, and 29 did not return for a follow-up. Seventy-five women were included (37 TRH, 38 SRH). Intervention: At one-year post procedure, subjects completed questionnaires: Pelvic Organ Prolapse Distress Inventory, (POPDI-6); Pelvic Organ Prolapse/Urinary incontinence Sexual Function Questionnaire, (PISQ-12);
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Case: We present a case of 32 y.o. female with a large, symptomatic, evolving vaginal wall cyst of unclear etiology. On examination, a cystic mass measuring 6 x 3 cm encompassing the right anterolateral vaginal wall was identified. Cystogram & MRI ruled out any communication between the cyst and the lower urinary tract.
Pathology confirmed a benign mullerian cyst lined with mucinous & squamous epithelium with associated chronic inflammation. The patient remained asymptomatic & is without recurrence. Discussion: This case differs from the norm with the cyst evolving in size & being increasingly symptomatic. Most mullerian cysts are less than 2 cm in diameter. When symptomatic, excision requires the entire cyst wall to be removed to prevent recurrence. The preponderance of vaginal wall cysts are diagnosed clinically as gartners duct cysts; however, the vast majority of cysts are histopathologically found to be of mullerian origin with the cyst wall characteristically lined by mucin producing epithelium in contrast to gartners duct cyst which are non mucin producing.
589 Surgical Management of Complex Uretheral Diverticulum Mama ST, Chaudhry U. Ob/Gyn, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey
The origin was either vaginal or bladder. Surgical excision of the cyst was performed with careful dissection from its attachment to the right lateral vaginal wall & periurethral tissue.
Cystoscopy with right ureteral stent placement was done intra-operatively prior to dissection. The stent was removed at the end of procedure.
Study Objective: Background: Urethral diverticulum is a herniation between the periurethral fibromuscular layer and anterior vaginal wall continuous with the lumen of the urethra. The incidence is 1 to 6%.It occurs commonly in the third to fifth decade of life. The condition can be acquired or congenital. The etiology is not understood. The most widely accepted theory is obstruction and subsequent infection of the periurethral glands with rupture of the abscess into the lumen. Other causes include trauma from vaginal or urethral surgery and childbirth trauma.The diagnosis of urethral diverticulum can be confused with vaginal wall inclusion cysts,mesonephric or paramesonephric cysts, Skene gland cysts, urethral caruncles, and urethroceles. Case: A 52 year old surgically postmenopausal female presented with severe symphysis pubis and vaginal pain with painful urination. The pain preceded and was present during voiding. Physical exam was nonspecific. The patient required combined NSAIDs and narcotics for relief. CT scan and MRI confirmed a large 3 cm diverticulum.
The diverticulum occupied the entire urethral length occupying 270 degrees with the neck at the 8 oclock position. The patient had no risk factors. The diverticulum was dissected out entirely including the neck and excised. The defect in the urethral lumen was closed. Reconstruction of the posterior periurethral fibromuscular layer was done in a pants over vest technique. There were no post operative complications and patient had resolution of her symptoms. Conclusion: The clinical presentation of urethral diverticulum is varied, the diagnosis and management often delayed. Transvaginal excision of urethral diverticulum remains the gold standard. Success depends on determination of the extent and number of diverticula and attention to surgical technique. The recurrence rate is 11%. This case is unusual in
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
S179
583 Modified Technique for the Placement of Sub-Urethral Sling Tension-Free Polypropylene Mesh in Patients with Stress Urinary Incontinence Morgan-Ortiz F, Josefina B-B, Juan. Manuel S-P. Centro de Investigacion y Docencia en Ciencias de la Salud, Universidad Autonoma de Sinaloa, Hospital Civil de Culiacan, Culiacan, Sinaloa, Mexico
having no risk factors, sudden onset and the extent and size of the diverticulum.
590 Surgical Outcomes in the Use of Porcine Small Intestine Submucosal Graft (Cook Medical Biodesign Surgisis Posterior Pelvic Floor Graft) for Vaginal Repair of Pelvic Organ Prolapse Masone M, Jarnagin BK, Tatalovich JM, Ritch JMB. Center of Pelvic Health, Franklin, Tennessee Study Objective: To describe the use of porcine small intestine submucosal graft to aid in the vaginal prolapse repair with sacrospinous ligament suspensions in patients declining mesh and to report on preliminary outcomes. Design: Retrospective analysis on 19 consecutive cases of vaginal prolapse repair cases using graft. Setting: Hospital based private urogynecology practice. Patients: 19 women with pelvic organ prolapse. Intervention: Vaginal repair of pelvic organ prolapse using the Surgisis posterior pelvic floor graft. The graft arms were attached to the sacrospinous ligament utilizing an anchoring device. The body of the graft was attached to the vagina and the arms secured to the sacrospinous ligament bilaterally supporting the entire vagina. Measurements and Main Results: The 19 patients had an average age of 62 years (SD 11) and average BMI of 29.2 (SD 5.6). The mode preoperative pelvic organ prolapse quantification (POP-Q) stage was 2 (range 2-4). Of the 16 patients with a POPQ stage recorded at their 6 weeks post-operative visit, 12 patients were POPQ stage 0, 1 was POPQ stage 1 and 3 were POPQ stage 2. The mode change in stage was 2 (range 1-4). Two patients did not show for the 6 week post-operative visit. Of the 15 patients with follow-up at 3 months, 9 maintained their initial post-operative POPQ stage 0, two maintained their initial postoperative POPQ stage 2, and one patient increased from postoperative stage 1 to stage 2. Of the 3 patients with follow-up at 6 months, one maintained the 3 month POPQ stage 0 and two had increased. One patient increased from stage 2 to stage 3 at 6 months and one patient increased from stage 0 to stage 2 at 6 months. Conclusion: Preliminary data of the vaginal use of porcine graft shows that it is effective at reducing pelvic organ prolapse. Further study is needed to determine long-term efficacy and recurrence rates.
Study Objective: To describe the results of a modified technique for the placement of sub-urethral sling with polypropylene mesh in patients with stress urinary incontinence. Design: Prospective analysis of 62 cases of stress urinary incontinence undergoing anti-incontinence surgery and were followed from January 2005 to December 2010 at Hospital Civil de Culiacan, Sinaloa, Mexico. Setting: Public teaching hospital at Culiacan, Sinaloa, Mexico. Patients: Sixty two patients with stress urinary incontinence. Intervention: Modified technique using of Pereyra needle for placement of the sub-urethral sling with polypropilene mesh. This technique is a modification of the original technique of TVT (Gynecare TVTTM, Ethicon Women’s Health & Urology Ethicon, Inc.) Johnson & Johnson Company, Somerville, New Jersey, USA) which was replaced by a monofilament polypropylene mesh (25 x 25 cm, SPMLI, PROLENE Soft Polypropylene Mesh, Ethicon, Inc.) Johnson & Johnson Company, Somerville, New Jersey, USA). This mesh was cut in pieces of 1,5 cm wide by 8 cm long (Off label use) and placed underneath the mid-urethra with the aid of needle Pereyra. Measurements and Main Results: The cumulative cure rate at 12, 24, 36, 48 and 60 months were 96,7% (n = 60), 91,9% (n= 57), 90,3% 8n = 56), 90,3% (n = 56) and 85,5% (n= 53) respectively. The mean length of the procedure was 35,7 minutes (SD:14,2). The mean intraoperative bleeding was 138,7 ml (SD: 88.2.) (R: 50 ml to 200 ml). The frequency of complications were: residual cystocele (3.2%), extrusion of material through vaginal mucosa in three cases (4.8%). There were no cases of bladder injury, bowel injury, urinary retention or bladder erosion. Conclusion: The placement of the tension-free sub-urethral sling with modified technique using the Pereyra needle is a feasible and safe treatment option for patients with stress urinary incontinence, with similar cure rates and less morbidity than that reported in the literature with the original TVT.
591 Outcomes of Total Robotic Hysterectomy Versus Supracervical Hysterectomy with Sacrocolpopexy for Uterovaginal Prolapse at One Year Myers EM,1 Siff L,2 Osmundsen B,3 Geller EJ,1 Matthews CA.1 1Female Pelvic Medicine and Reconstructive Surgery/OBGYN, university of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 2Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts; 3Obstetrics and Gynecology, Providence Medical Center, Portland, Oregon Study Objective: To determine if there is a difference in recurrent pelvic organ prolapse (POP), defined as > Stage II by the Pelvic Organ Prolapse Quantification system (POP-Q), at one year after undergoing total robotic hysterectomy (TRH) versus supracervical robotic hysterectomy (SRH) at the time of robotic sacrocolpopexy (RSCP) for uterovaginal prolapse. Design: Retrospective cohort analysis. Setting: University of North Carolina Hospital and Providence Medical Center. Patients: One hundred and nine women who underwent hysterectomy with RSCP over a 24-month period were identified, five declined participation, and 29 did not return for a follow-up. Seventy-five women were included (37 TRH, 38 SRH). Intervention: At one-year post procedure, subjects completed questionnaires: Pelvic Organ Prolapse Distress Inventory, (POPDI-6); Pelvic Organ Prolapse/Urinary incontinence Sexual Function Questionnaire, (PISQ-12);