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PubMed1982

Randomized comparative study of culdoscopy and minilaparotomy for surgical contraception in women.

Informed, healthy, volunteering women seeking interval sterilization were randomly allocated either to culdoscopy or to minilaparotomy. Data concerning the operation and follow-up to six weeks post-operation were analyzed for 199 women in the culdoscopy group and 196 in the minilaparotomy group. Major complications, both at operation and subsequently, occurred only in the vaginal procedure group (3%). Minor complications occurred in 3.6% of women in the minilaparotomy group, the majority of these involving the abdominal wound. In the women operated vaginally, minor complications occurred in 1.5%. Failure to perform the intended procedure on the fallopian tubes occurred in 10.6% of culdoscopy cases and 0.5% of minilaparotomy cases. It is concluded that the vaginal approach cannot be recommended except for surgeons experienced in vaginal surgery.

Adult↗
PubMed2004

Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH.

STUDY OBJECTIVE: To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Tertiary teaching hospital. PATIENTS: Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION: LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS: There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury. The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION: LAVH type IA achieved better results than type ID in preventing bladder injury.

Blood Loss, Surgical↗
PubMed1995

Transvaginal small-bowel evisceration: a case report.

Transvaginal small-bowel evisceration is rare. Only 47 case reports appear in the literature in English. Review of this literature shows that vaginal evisceration occurs mainly in women who are older, multiparous, and have undergone vaginal surgery. The immediate cause of evisceration is either sudden, increased intraabdominal pressure, trauma, or a spontaneous event. The small bowel and omentum are most commonly involved. Surgical repair is performed vaginally, abdominally, or by both methods. We present a case of transvaginal small bowel evisceration caused by inadvertent self-induced trauma, a heretofore unreported cause of this complication, in a 79-year-old woman with known weakness of her pelvic structural support. She experienced sudden evisceration of small bowel following manual decompression of her cystocele during voiding. We used a combined abdominal and vaginal approach to examine the small and large intestines and mesentery for trauma, attach the vaginal vault to the shortened uterosacral ligament, obliterate the cul-de-sac using the Moschowitz procedure, and repair the defect in the levator plate. To limit risk, patients should be evaluated for predisposing conditions. We recommend a combined abdominal and vaginal surgical approach to adequately evaluate the involved tissues and to effect repair.

Aged↗
PubMed1985

[Preoperative laparoscopy for determination of the surgical approach].

131 selected patients underwent preoperative laparoscopy directly before surgery and under the same anaesthesia during the period 1981-1984. In all 131 patients several findings were present in combined form that would have permitted abdominal surgery only, provided laparoscopy had not been performed. 49 patients were operated upon via the abdominal approach even though they had been subjected to laparoscopy. In 82 patients, the more favourable vaginal approach was rendered complicated by additional findings (in 22, antefixating preliminary operations on the uterus after Doléris or Baldy; in 29, cystic adnexal tumours; in 31, adhesions or unclear conditions of pain following known or unknown previous surgery). By preceding surgery by laparoscopy it became possible to treat these patients in such a manner that the subsequent vaginal operation was without risk and free from complications. Preoperative laparoscopy extends, enables and safeguards the indication for vaginal surgical approach if used with the necessary critical discrimination.

Aged↗
PubMed2004

Pubo-fascial versus vaginal sling operation for the treatment of stress urinary incontinence: a prospective study.

AIMS: To compare the long-term results of stress urinary incontinence (SUI) treatment involving the fascial or vaginal sling operations. MATERIAL AND METHODS: Two-hundred-thirty-two women were consecutively submitted to fascial or vaginal sling operations due to urodynamic proven SUI. The fascial group had a median age of 47.3 years with a parity of 2.2 and 1.8 surgeries/patient, while the vaginal group demonstrated a median age of 48.5 years with a median parity of 3.1 and 2.2 anterior surgeries/patient. The results were subjectively classified as cured--no further pads, greatly improved--very rare dribbling, improved--eventual dribbling necessitating one pad, no cure--with no urine loss change and worse. The number of pads/day, the presence of urgency or urge-incontinence episodes were all measured. Statistical analysis using Fisher's exact test was employed. RESULTS: The patients were followed up for an average time of 70.3 and 44.9 months, in the fascial and vaginal sling group respectively. Subjective clinical success rate was 93.7% for the fascial sling group and 79.8% for the vaginal one, however, the stratification of the results favored the fascial sling group mostly with 74.4% (94 cases) of the cases with total urinary control and no voiding dysfunctions. Only two cases (1.6%) in this group classified themselves as worsened. On the other hand, the vaginal sling subset revealed cure with total clinical satisfaction and no urinary complaint in 61.5% (62 females) (P > 0.05). Thirteen cases (12.5%) reported recurrence of the urine loss under stress and these constituted the failure group. The average number of pads diminished from 3.3 (+/- 0.8) to 0.2 (+/- 0.2) and from 3.2 (+/- 0.7) to 0.6 (+/- 0.5) after the surgery, for the fascial and vaginal sling operations respectively. Return to daily activities occurred after 9.3 days (+/- 1.2, max: 33, min: 2) for the fascial slings and 5.3 days (+/- 0.2, max: 17, min: 2) in the vaginal group. Surgical complications were compared between the groups. Time to urethral voiding varied according to expertise, demonstrating a diminishing tendency after the initial 20 cases. Female obstruction was observed in 11.1% of the fascial slings and 8.6% after vaginal approach, but none in the vaginal group required urethrolysis. Looking individually, the FS group migrated to the worse results while the VWS group started to lose the efficiency after 6 months. CONCLUSIONS: Sling operations are a safe and efficacious option to treat SUI, however, the results can vary according to the technique employed. Shorter efficacy and fewer complications are observed in vaginal wall sling operations, while durable results, but with a higher rate of voiding dysfunctions compromising the long-term clinical satisfaction may be observed after excessive urethral suspensions, as in fascial sling suspension.

Female↗
PubMed2002

Elective hysterectomy at Tikur Anbessa Teaching Hospital, Addis Ababa.

A retrospective analysis of 969 elective hysterectomies performed at Tikur Anbessa teaching hospital from February 1992-October 2000 is presented. The objectives of the study were to outline the major indications, the frequencies of intraoperative and postoperative complications and the variations of these frequencies in the various types of hysterectomy, thereby providing data on this important gynaecologic operation in an Ethiopian hospital set-up. Elective hysterectomies accounted for 79.3% of all hysterectomies performed at the unit. There was a preference for the abdominal approach to hysterectomy (77.3%) with vaginal hysterectomy being done in only 22.7%. The three major indications for hysterectomy were leiomyoma 396/969 (41.1%), uterovaginal prolapse 221/969 (23%) and ovarian tumours 188/969 (19.5%). 567/969 (58.5%) of the patients had an underlying medical condition; anaemia being the commonest, accounting for 325/969 (33.5%). In 294/969 (30.2%) of the operations, intraoperative adhesions requiring adhesiolysis were encountered. A high proportion of intraoperative complications 167/969 (17.2%), and postoperative complications, 316/969 (32.6%), were found. Intraoperative haemorrhage rate 135/969 (14%) is significantly higher than reports from other series of hysterectomy. Postoperative febrile morbidity, 260/969 (27%), is also significantly higher than rates reported from other series. Unexplained fever was however lower, being responsible for only 20% of the febrile morbidity. There was a significantly increased risk of urinary tract infection in vaginal hysterectomies and unexplained fever in abdominal hysterectomy (P < 0.05). There is a need to use the vaginal approach to hysterectomy whenever feasible and introduce infection prevention protocols to reduce the high incidence of infection at the unit. Analytic studies to assess risk factors for haemorrhage and infection are required in order to devise preventive strategies.

Adolescent↗
PubMed1979

[The ramining cervical stump (author's transl)].

The subtotal hysterectomy is no longer indicated for the treatment of female genital disease with rare exceptions. It has been known for a long time that the remaining cervical stump has very few advantages but many potential risks. Among our patients who had cervical stumps removed 32 of 69 cases had malignant changes in the cervical stump. Decensus and prolapse was the next common abnormality. If adnexal tumors or cervical cancers do not indicate an abdominal approach for the removal, the vaginal approach for the removal of the cervical stump ist preferred since this is easier and less risky.

Adult↗
PubMed1995

The evolution of methods for female sterilization.

Methods for the sterilization of women by occlusion of the Fallopian tubes have evolved by changes in the approaches to the tubes and trials of various methods for occluding the tubal lumen. Approaches to the tube have included: the anterior abdominal wall routes by laparotomy, minilaparotomy and laparoscopy; a vaginal approach through the posterior vaginal fornix; and transcervical approaches, either blind, or via the hysteroscope. Methods for obtaining tubal occlusion have included: excision and suture techniques; electrocautery; clips and rings; intratubal occlusive devices and chemicals introduced into the tubal lumen. The development of each of the approaches to the tube and of the methods for obtaining tubal occlusion are discussed.

Electrocoagulation↗
PubMed1998

[Long-term outcome of incontinence and prolapse surgery at the Heidelberg University Gynecologic Clinic 1980-1992].

OBJECTIVE: Long-term results after different types of operations for urinary stress incontinence (minimum follow-up: 18 months) as well as multiple risk factors for the pelvic floor were analysed in a retrospective study. STUDY DESIGN: Between 1980 and 1992 1283 patients underwent surgery because of urinary stress incontinence at the University Women's Hospital in Heidelberg. The data of 478 patients, 430 of these after primary and 48 after recurrent surgery, were evaluated by questionnaires with regard to the long-term-results. RESULTS: 57% of patients after primary surgical therapy and 37% after recurrent surgery were cured for longer than 5 years or since the operation. A cure or improvement of the incontinence could be observed in 80% after primary and in 73% after recurrent surgery. Among the vaginal approaches for primary surgery the hysterectomy combined with colporrhaphy was most successful (60% cured or more than 5 years continent, 80.5% at least improved). The Burch colposuspension revealed even better results among the abdominal approaches (64% cured or longer than 5 years continent, 86% at least improved) compared to the Marshall-Marchetti-Krantz procedure with a cure rate of 33%. For therapy of the recurrent urinary incontinence the abdominal Burch colposuspension showed the best results with cure rates of 50% and cure or improvement in 75%. Therefore the abdominal approach seems to be superior to vaginal techniques such as sling operations (33% cure rate, 67% at least improved) or only re-colporrhaphy (27% cure rate, 78% at least improved). CONCLUSION: For primary incontinence the hysterectomy with vaginal repair or the Burch colposuspension have proved to be most successful. For recurrent urinary incontinence the abdominal colposuspension (Burch procedure) seems to be superior to other approaches.

Adult↗
PubMed1997

[Vesicovaginal and urethrovaginal fistulae].

The authors discuss treatment of vesicovaginal fistulae (VVF) in 36 patients and in six patients urethrovaginal fistulae treated in 1989-1995. The most frequent cause of VVF were iatrogenic lesions after hysterectomy. Occlusion of the fistula was performed 12x by the transvesical approach, nine times by a combined transperitoneal and vaginal approach, four times by a transvesical and transperitoneal approach, eight times by the vaginal route only and three times the authors had to make a continent derivation of urine of the sigma-rectum "pouch" type. Continence by primary operation was achieved in 86%, in urethrovaginal fistulae one reoperation was necessary. With the development of radical operations in the lesser pelvis in women the incidence of iatrogenic lesions is rising slightly, however when the technique of minimal invasive reconstruction urology is used, the prognosis of occlusion of fistulae is favourable.

Adolescent↗
PubMed1977

The closure of urinary-vaginal fistulas.

Reported series of urinary-vaginal fistulas repaired by a vaginal approach show at least 85% primary closure. However, many patients have had several unsuccessful operations elsewhere prior to the final repair. This means that regularly successful closure is possible, but it demands a certain "know-how" and engagement. In search for the general principles leading to such successful primary closure, different published techniques have been studied. It appears that the essential features are the establishment of a proper distance between the inner vesical and the outer vaginal epithelium and the creation of broad raw surfaces to be ajoined. The operation should not involve any risk of enlarging the existing fistula, and the transfer of normal tissue to the site of the repair and the interposition of tissue between the cavities to be separated are sound reconstructive procedures. A personal technique based on these principles is presented. The gynecologists of to-day most often refer urinary-vaginal fistulas to the urologists, who almost without exception prefer a suprapubic transvesical approach. It is strongly recommended that the large majority of urinary-vaginal fistulas should be repaired by the vaginal approach which is a minor intervention. The plastic surgeon should be engaged in the management of urinary-vaginal fistulas.

Female↗
PubMed1983

Management of giant vesicovaginal and vesicourethrovaginal fistulas.

We herein report on 15 patients with giant vesicovaginal (7) and vesicourethrovaginal (8) fistulas repaired since July 1979. All fistulas were repaired by a suprapubic approach with or without a concomitant vaginal approach. All 7 patients with giant vesicovaginal fistulas underwent a standard racket incision of the bladder with excision of the fistula, closure of the vagina and bladder, and an omental interposition, and were cured. Four patients with giant vesicourethrovaginal fistulas had a similar successful closure but only 2 were cured of the incontinence, while 2 remained totally incontinent owing to failure of the bladder outlet sphincteric mechanism. The latter 2 patients were managed by a Tanagho bladder flap urethral reconstruction: 1 remained totally incontinent and finally underwent diversion, while 1 was improved but not cured totally. Four patients were managed by repair of the fistula simultaneously with a Tanagho bladder flap: 2 had no previous abdominal repairs and both achieved continence postoperatively, while 2 had numerous attempts at repair (including abdominal approaches) before referral and only 1 was cured. Giant vesicovaginal fistulas can be repaired successfully in almost all patients. Although vesicourethrovaginal fistulas can be closed as readily there is a high likelihood of sphincteric inadequacy in patients with extensive urethral involvement. A bladder flap urethral reconstruction is valuable in these patients, particularly in the absence of prior suprapubic procedures.

Female↗
PubMed1997

Currycombs for the vaginal paravaginal defect repair.

BACKGROUND: The paravaginal defect, present in more than three-quarters of patients with cystoceles, can be repaired by both the abdominal and vaginal approaches. The technical challenges of the vaginal paravaginal repair have militated against its widespread adoption by gynecologic surgeons. INSTRUMENT: Currycombs can be used to facilitate suture management during vaginal paravaginal repair. EXPERIENCE: The vaginal paravaginal repair using currycombs was performed as part of pelvic repair surgery on 27 patients. Perioperative complications were minimal. A cystocele cure rate of 80% was achieved after a mean follow-up of 8 months. CONCLUSION: The use of currycombs during performance of the vaginal paravaginal repair facilitates suture management. The addition of this technique should help gynecologic surgeons to perform this somewhat daunting surgical procedure.

Female↗
PubMed1989

[A simple technic for vaginal suspension using multiple approaches. Study of a series of 50 cases].

Fifty patients underwent vaginal suspension using a new technique based on Stamey's procedure. The method of operation is described with illustrations. This procedure can be carried out with the patient in the lithotomy position when special indications are present: when prolapse has to be cured by the vaginal route and a vaginal suspension has to be carried out; when a vaginal hysterectomy has to be carried out together with a vaginal suspension; when an upper approach vaginal suspension using a Marshall-Marchetti technique has failed. The advantages of this technique seem to the authors to be: the simplicity of the procedure: only the lithotomy position is needed. It is easy and quick to carry out, it is safe: dissecting out the bladder from the vaginal approach and passing threads from below to above practically completely avoids the risk of damaging the bladder. The preliminary clinical and uro-dynamic results are given.

Adult↗
PubMed1994

Abdominal hysterectomy versus transvaginal morcellation for the removal of enlarged uteri.

OBJECTIVE: The purpose of this study was to compare the intraoperative and postoperative complications of transvaginal morcellation and abdominal hysterectomy for the removal of moderately enlarged uteri. STUDY DESIGN: An observational study was performed on all uteri weighing > 200 gm removed transvaginally from July 1, 1987, to June 30, 1993. An abdominal hysterectomy control group was selected. RESULTS: There were 50 patients in the vaginal group and 112 in the abdominal group. At a p value < 0.05 there was no statistically significant difference between the two groups for age, parity, obesity, hypertension, insulin-dependent diabetes mellitus, or prior genitourinary surgery. The mean operative time in the vaginal hysterectomy group was 122 minutes and in the abdominal hysterectomy group 148 minutes (p < 0.05). The mean estimated blood loss was 527 and 586 ml, respectively (not significant). Twenty-two percent of the vaginal group and 70% of the abdominal group underwent bilateral oophorectomy (p < 0.05). The mean uterine weights were 335 and 336 gm, respectively (not significant). The mean day of starting a regular diet was 2.1 and 3.6, respectively (p < 0.05). The mean day of discharge was 3.6 and 5.1, respectively (p < 0.05). Complications were similar for the two groups. CONCLUSIONS: In selected patients transvaginal morcellation is a safe and effective alternative to abdominal hysterectomy for the removal of moderately enlarged uteri. The two procedures are comparable in operative time, blood loss, and complications. Both ovaries are more likely to be removed with abdominal hysterectomy. Cosmesis and recuperation may be advantages of the vaginal approach.

Adult↗
PubMed2005

Bladder mucosal autografts for repair of vesicovaginal fistula.

Twenty-two women with primary and secondary (five patients) vesicovaginal fistula attending a tertiary level urological unit in India were treated by repair of the fistula using bladder mucosal autografts. The fistula was approached transabdominally or via a combined abdominal and vaginal approach (for those involving the trigone). After closure of the vaginal layer, bladder mucosa was harvested from the dome of the bladder and laid over the fistula with sutures at each corner to fix it in place. Patients were catheterised for 12-14 days. At follow up after 3 to 12 months, 20 out of 22 patients were continent, with no other symptoms. The two failures had undergone two previous repairs each. This series is the first from India, and demonstrates the efficacy of bladder mucosal autografts for managing large fistulae, those where a previous repair has failed and fistulae adjacent to the ureteric orifice without the need for uretero-neocystostomy.

Adult↗
PubMed2001

Vaginal reconstruction/fistulae.

Vaginal reconstruction is required in congenital absence of the vagina in the paediatric population and in patients with surgical (anterior exenteration) or traumatic loss of the vagina. Although vaginal agenesis is rare, its description and attempts at replacement vaginoplasty date back to antiquity. Different forms of vaginal reconstruction are described, including the use of split-thickness or full-thickness grafts, amnion, peritoneum or bowel. Experience with bowel segments for vaginoplasty, with few complications and high success rates, have expanded the indications for this technique, rendering it of great importance in the field of vaginal reconstruction, especially when large bowel segments are utilized. Most vaginal fistulae occur after gynaecological surgery. There is a multitude of established techniques for closure of vaginal fistulae with comparable success rates, and two different approaches (vaginal or abdominal) may be used. Preferable for complicated or recurrent fistulae is the abdominal approach because a well vascularized pedicled omentum majus flap can be interposed. Postirradiation fistulae, although rare, represent a challenge for the reconstructive surgeon. Fistula excision and closure fails in a high percentage of patients, and in cases of additional bladder and vaginal shrinkage urinary continence can only be achieved by urinary diversion.

Female↗
PubMed1975

Gynaecologic surgery on elderly patients.

To evaluate the risks associated with gynaecologic operations on elderly patients (60 years or over) we performed this retrospective study of 573 operations. More than half the patients (53%) were operated on because of uterine prolapse. An abdominal operation was done in 33%, a vaginal approach in 59% and a combined abdominal and vaginal procedure in 9%. (he total amount of postoperative complications was 26% and higher after abdominal (36%) than vaginal operation (19%). Most complications were mild, e.g. fever (16%) and wound complications (4%). Five patients (0.87%) died within one month postoperatively, but only in two cases was death caused by postoperative complication itself, namely cardiac infarction and pulmonary embolism. It appears that our procedures based on co-operation between gynaecologist, internist and anaesthetist yield good results and that the chronologic age in itself is only seldom a contraindication to operative treatment.

Age Factors↗