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PubMed2003

Dynamic evaluation of female pelvic organ prolapse by extended proctography.

More accurate preoperative assessment by DCP or MR imaging hopefully should reduce the incidence of operative failure. These techniques help the surgeon to plan the different components of pelvic reconstructive surgery and, importantly, whether a transvaginal or transabdominal approach will be required. The current trend is toward the transabdominal route. Available evidence suggests that the reoperative rate is halved when the abdominal approach is employed. Large enteroceles and marked vaginal vault prolapse, in particular, are much more amenable to correction by transabdominal surgery. It should be recognized that enteroceles and sigmoidoceles often escape preoperative detection unless radiologic evaluation is performed. Global assessment of pelvic organ prolapse is optimized by ensuring that competing organs are effectively emptied by virtue of a triphasic approach. As expressed succinctly by Halligan, "the global pelvic floor specialist has arrived, and his closest ally is the radiologist".

Barium Sulfate↗
PubMed2002

Hong Kong Chinese women's experiences of vaginal examinations in labour.

OBJECTIVE: to explore women's experiences during vaginal examinations in labour. DESIGN: qualitative with phenomenological approach. Data were collected by tape-recorded open-ended interviews during the early postnatal period. DATA ANALYSIS: phenomenological hermeneutic analysis based upon Riceour's interpretation theory. PARTICIPANTS: a purposive sample of eight women post-delivery who had given birth vaginally and were able to speak and read Chinese. SETTING: a maternity unit of a University affiliated District General Hospital in Hong Kong. KEY FINDINGS: women accepted the necessity for vaginal examinations, but expressed the need to be able to trust that the examiner would respect them as individuals and try to maintain their dignity, perform the examination skillfully and communicate the findings to them. Pain and embarrassment were frequently experienced during vaginal examination. Women wanted to be supported during the examination by someone they knew and trusted; they appreciated practitioners who tried to minimise their physical and psychological discomfort. Some women felt embarrassed when examined by a male doctor, but the attitude and approach of the examiner was generally found to be more important than gender. IMPLICATIONS FOR PRACTICE: practitioners should be continuously aware of the need to show respect and consideration for the dignity of a woman undergoing vaginal examination in labour. Although this seems an obvious statement to make it is reiterated because some practitioners display insensitivity in this regard. Each woman should be treated with courtesy and respect, and her modesty protected by minimal exposure and examiners/examinations. Findings from the examination should be discussed with her. Practitioners should be aware of the cultural influences that may lead a woman to hide her pain during examination and should be alert for signs of this.

Attitude to Health↗
PubMed2005

Health economics of hysterectomy.

Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.

Cost-Benefit Analysis↗
PubMed1998

Patterns of prolapse in women with symptoms of pelvic floor weakness: magnetic resonance imaging and laparoscopic treatment.

Magnetic resonance imaging represents a new method of imaging the pelvic viscera and pelvic floor musculature. Rapid sequences allow us to perform magnetic resonance imaging dynamically during straining or pelvic floor contraction, which can elegantly demonstrate the patterns of pelvic floor prolapse. The technique is relatively quick, noninvasive, and does not use ionizing radiation. The principle of the laparoscopic approach is to imitate the conventional abdominal or vaginal techniques. Laparoscopic sacrospinous fixation or sacral colpopexy using a graft as well as the laparoscopic repair of enteroceles and rectoceles may offer some advantages over the classic approach. As comparative prospective studies are still missing, the role of laparoscopy in the management of pelvic floor defects remains to be defined.

Female↗
PubMed1988

Laparoscopic and vaginal colpotomy for the excision of infiltrating cul-de-sac endometriosis.

Palpable endometriotic nodules deep in the cul-de-sac and vagina represent the extension of intraperitoneal disease. Although such nodules used to be excised with vaginal colpotomy and by tracing the endometriosis to the peritoneum, the dissection of these lesions under laparoscopic visualization had aided in their removal. Of seven patients who were approached with a plan for combined laparoscopic and vaginal excision, five underwent the procedure. The last two required laparotomy due to bowel muscularis involvement.

Douglas' Pouch↗
PubMed2000

Combined laparoscopic and vaginal radical surgery in cervical cancer.

OBJECTIVE: The purpose of our study was to review our experience with laparoscopic staging and vaginal radical surgery in the treatment of early stage cervical cancer. STUDY DESIGN: We reviewed the charts of 102 patients who had a laparoscopic pelvic lymphadenectomy followed by vaginal radical hysterectomy (VRH) or vaginal radical trachelectomy (VRT). RESULTS: Patients' age ranged from 25 to 68 years (median: 36). Squamous and adenocarcinoma histology occurred in 68 and 32%, respectively. Stage Ib1 occurred in 77% of cases and the rest were stage Ia1 (1%), 1a2 (16%), and IIa (6%). Patients were divided into three groups: VRH (57), VRT (34), and node only (NO) (11), when positive nodes were identified on frozen section. Median operative time for VRH and VRT were 270 and 260 min compared to 200 min in the NO group (half also had bilateral paraaortic node dissection, which lengthened the OR time). Hospital stay was shorter in the NO group (2 days). For each group (VRH, VRT, and NO) the median pelvic node count was 27, 26, and 23 and the median paraaortic node count was 3, 4, and 9. Two VRH were converted to an abdominal procedure because of technical difficulties and one VRT was converted to a VRH because of positive endocervical margins. Intraoperative complications related to laparoscopy included two iliac and one epigastric vessel injuries. Complications related to the radical surgeries included three cystostomies, managed vaginally, and a laparotomy for parametrial bleeding after VRT. Postoperative complications occurred in 6% of patients and only one was considered major (an abscess which required surgical drainage). Overall, there were only four recurrences in the vaginal surgery groups and one in the NO group. There were no ureteral or intestinal injuries and there have been no trocar site recurrences. CONCLUSION: Our data show that approaching cervical cancer with a combined laparoscopic and vaginal surgery is feasible. The overall morbidity and complication rate are low and the lymph node count is satisfactory. Staging the nodes laparoscopically first to identify positive nodes is advantageous, particularly since we favor the use of chemoradiation therapy in those cases. The laparoscopic node staging thus avoids an unnecessary laparotomy in patients with positive nodes, reduces morbidity, and allows for early radiation therapy.

Adenocarcinoma↗
PubMed1995

[Complete hysterectomy for benign pathology and laparoscopy: respective indications of laparoscopic preparation and an exclusively laparoscopic approach].

According to whether uterine artery treatment takes place vaginally or laparoscopically, laparoscopy for hysterectomy can be considered according to two modalities: laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH). The indications for laparoscopy are defined by the limits and/or contraindications of the vaginal route. LAVH is indicated in the following situations: pelvic pain syndrome where diagnosis and treatment can be made at the same time as hysterectomy; minimal endometriosis; past surgical history favouring adhesions formation; necessity to perform an oophorectomy; existence of an ovarian pathology. The elective indications for TLH are the severe pelvic adhesions, deep endometriosis and especially a limited vaginal accessibility associating with a narrow vagina and a fixed or non prolapsed uterus. Laparoscopy thus allows to reduce the number of laparotomies. When on overage three quarters of the hysterectomies (excluding cases of uterogenital prolapse) were up till now performed abdominally, laparoscopy could reduce this rate to approximately 10%.

Elective Surgical Procedures↗
PubMed1993

Laparoscopic-assisted vaginal hysterectomy: report on 32 initial cases.

Techniques for laparoscopic-assisted vaginal hysterectomy are being developed in the hope that these new techniques will improve patient care. This article reviews the initial experience of the author with the Endo-GIA stapling device in performing laparoscopic-assisted vaginal hysterectomy. The results showed this technique to be an attractive alternative to the traditional abdominal approach.

Female↗
PubMed2004

Women's experiences with low-risk singleton in-hospital delivery in Switzerland.

OBJECTIVE: To assess maternal and neonatal clinical short-term outcomes and women's experiences with singleton low-risk in-hospital deliveries in a routine care setting. METHODS: In 13 community hospitals in the Cantons of Zurich (10), St. Gallen (2) and Schwyz (1), participating in the "Canton of Zurich Outcomes Project", trained hospital staff recorded clinical outcome data. Patients completed a questionnaire at the end of the hospital stay. Over two measurement cycles, 3395 eligible women entered the study and 2079 (61%) returned the questionnaire. RESULTS: Sixty-seven percent of women had spontaneous and 11% had assisted vaginal deliveries, 12% delivered by emergency, and 10% by elective Caesarean section. The episiotomy rate in vaginal deliveries was 46% (95% CI 44-48%). Ten percent of neonates had umbilical cord artery pH < or =7.15 (95% CI 9-11%) and Apgar scores at five minutes were < or = 7 in 3% (95% CI 2.5-3.6%). Reporting negative experiences with hospital care and an insufficient state of knowledge at discharge were strongly associated with mode of delivery. The top three issues new mothers were most likely to report about feeling little or not informed about were postpartum pelvic floor exercises (22%), management of vaginal bleedings (12%), and alternatives of infant feeding (10%). CONCLUSION: In a setting of routine care poor short-term outcomes were rare in women giving birth in hospitals, and neonates and most mothers were discharged with a level of information that at least ensured a smooth transition to follow-up maternal care. Poor clinical results and patient-reported negative experiences concentrate in few individuals. Restrictive approaches that reduce the frequency of instrumental vaginal delivery, and routine episiotomy remain an important objective for quality improvement.

Adult↗
PubMed1995

The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital.

OBJECTIVE: Our purpose was to evaluate the medical and economic impact of of operative laparoscopy on the surgical approach to hysterectomy for benign disease in a large, metropolitan, not-for-profit hospital. STUDY DESIGN: Retrospective analyses were performed on 2563 hysterectomies (without vaginal or bladder repair) for benign disease, performed by 37 gynecologists between January 1991 and December 1993. Disposable laparoscopic instruments and stapling devices were not used at any time during the study period. Electrosurgery and sutures were used for hemostasis. Parameters analyzed included surgical approach (total abdominal hysterectomy, vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and failed laparoscopically assisted vaginal hysterectomy), operative time, postoperative diagnosis, operative blood loss, length of stay, complications, uterine weight, and hospital changes. Charges in each of these parameters were analyzed and compared in 6-month increments. RESULTS: During the study period the percent of hysterectomies performed abdominally declined from 65% to 36%. Laparoscopically assisted vaginal hysterectomy increased from 12% to 45%, and vaginal hysterectomy varied from 23% to 19%. Average operative time was 82 minutes (+/- 2 minutes) for total abdominal hysterectomy, 102 minutes (+/- 2.3 minutes) for laparoscopically assisted vaginal hysterectomy, and 63 minutes (+/- 2 minutes) for vaginal hysterectomy. Hospital stay was 68 hours (+/- 1.5 hours) for total abdominal hysterectomy, 44 hours (+/- 1.2 hours) for laparoscopically assisted vaginal hysterectomy, and 43 hours (+/- 4.1 hours) for vaginal hysterectomy. The average hospital charge was $6552 (+/- $108) for total abdominal hysterectomy, $6431 (+/- $100) for laparoscopically assisted vaginal hysterectomy, and $5869 (+/- $116) for vaginal hysterectomy. CONCLUSIONS: Contrary to previously published studies, our study demonstrates (1) laparoscopically assisted vaginal hysterectomy is a cost-effective procedure when performed with reusable instruments, (2) laparoscopically assisted vaginal hysterectomy is a safe procedure, even when performed by a variety of gynecologists with different skill levels, and (3) the number of hysterectomies performed abdominally was decreased by 29% without incurring more complications or reducing the number of vaginal cases.

Blood Loss, Surgical↗
PubMed1981

The bicycle seat stool in the treatment of vaginal agenesis and stenosis: a preliminary report.

A new pressure technique for treatment of vaginal agenesis and stenosis, with the use of the bicycle seat stool, specifically designed Lucite dilators, and the patient model, is described. Experience with this method in 24 patients over a 5-year period produced coital function in 10 of 12 patients with vaginal agencies and 10 of 14 patients and various types of stenosis. Favorable experience with this technique, as compared to a previous 5-year period, in which the majority of vaginal agenesis was managed by the Abbe-McIndoe operation, has led to reversal of primary therapy of vaginal agenesis and stenosis from a surgical to a nonsurgical approach.

Contracture↗
PubMed2005

[Management of serious infectious complications of transobturator suburethral tape: report of 2 cases].

Suburethral TVT tape has become immensely popular since its invention in 1995. A new transobturator surgical approach was proposed in 2001, resulting in a modification of the quality of the tape available from various suppliers. The authors present 2 cases of obturator foramen abscess related to suburethral Uratape, occurring a long time after the procedure and requiring complete removal of the tape. These infections can be prevented by using good quality tape, which must be made from monofilament large-mesh woven polypropylene. The tape must be completely removed as early as possible in the case of vaginal erosion, even asymptomatic, via a transobturator approach, if necessary.

Abscess↗
PubMed2006

[Novel surgical procedure for the treatment of female stress urinary incontinence by using transobturator vaginal tape].

INTRODUCTION/AIM: Current method in the treatment of female urinary incontinence implies the placement of tension-free suburethral vaginal tape, using a retropubic or transobturator approach. Considering numerous complications related to retropubic approach, we reported the results of transobturator procedure in prospective study. METHODS: We used a non-absorbable polypropylene tape with the outside-in (Herniamesh) or in-outside (Johnson & Johnson) transobturator approach. RESULTS: During the period from October 2004 to September 2005 the procedure was carried out in 10 patients. In only 2 cases urinary stress incontinence occured as isolated problem managed with transoburator tape, whereas in 8 patients this procedure was associated with other operative gynecologic events. No perioperative complication was encountered. In 80% of the patients a satisfactory result was obtained, while one patient failed to demonstrate any amelioration, and the other developed subsequently urge incontinence. CONCLUSION: Transobturator tesion-free vaginal tape represents a very simple, safe and, in the large percent of cases, successful procedure in the management of urinary stress incontinence, with rare perioperative complications.

Adult↗
PubMed2004

Vaginal leucocyte counts in women with bacterial vaginosis: relation to vaginal and cervical infections.

OBJECTIVES: To evaluate whether an elevated vaginal leucocyte count in women with bacterial vaginosis (BV) predicts the presence of vaginal or cervical infections, and to assess the relation of vaginal WBC counts to clinical manifestations. METHODS: We retrospectively analysed the relation of vaginal leucocyte counts to vaginal and cervical infections and to clinical manifestations in non-pregnant women diagnosed with BV at an STD clinic visit. RESULTS: Of 296 women with BV studied, the median age was 24 years and 81% were African-American. Elevated vaginal leucocyte counts were associated with objective signs of vaginitis and cervicitis and also predicted candidiasis (OR 7.9, 95% CI 2.2 to 28.9), chlamydia (OR 3.1, 95% CI 1.4 to 6.7), gonorrhoea (OR 2.7, 95% CI 1.3 to 5.4), or trichomoniasis (OR 3.4, 95% CI 1.6 to 7.3). In general, as a screening test for vaginal or cervical infections, vaginal leucocyte count had moderate sensitivities and specificities, low positive predictive values, and high negative predictive values. CONCLUSIONS: An elevated vaginal leucocyte count in women with BV was a strong predictor of vaginal or cervical infections. Vaginal leucocyte quantification may provide an alternative approach to assessing need for empirical therapy for chlamydia and gonorrhoea, particularly in resource-limited high STD risk settings that provide syndromic management.

Adolescent↗
PubMed2005

Efficacy of functional electrical stimulation-biofeedback with sexual cognitive-behavioral therapy as treatment of vaginismus.

OBJECTIVES: To report 12 cases of vaginismus that were successfully treated with functional electrical stimulation (FES)-biofeedback with sexual cognitive-behavioral therapy (SCBT) to determine the efficacy of FES-biofeedback with SCBT as a standard therapy for vaginismus. Vaginismus is an involuntary spasm of the musculature of the outer third of the vagina that leads to impossible vaginal penetration, causing personal distress. Various therapeutic approaches, both physiologic and psychological, have been considered. METHODS: Twelve women with vaginismus referred from a checkup outpatient clinic participated in this study. The patients enrolled in this study had vaginismus according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders. The patients were assessed before and after treatment with gynecologic examinations and structured interviews pertaining to sexual function and psychological adjustment. After the diagnosis of vaginismus, we conducted weekly pelvic floor muscle relaxation using FES-biofeedback. Once the patients became tolerable to vaginal manipulation, the eight-stage SCBT (eight-stage gradual desensitization described by Kaplan using vaginal self-dilation with fingers and vaginal probe insertion) was added for 8 weeks. RESULTS: After 8 weeks of treatment, all 12 couples had completed the program, had become tolerable to vaginal insertion of larger size probes, and could achieve satisfactory vaginal intercourse. CONCLUSIONS: FES-biofeedback with SCBT is an effective aid for patients with vaginismus to learn muscle control. Therefore, it may increase the success rate of treatment of vaginismus.

Adult↗
PubMed2003

[Vesico-vaginal fistula: report of 1050 cases].

The authors reports their experience of a large series of 1050 cases of vesico-vaginal fistulas recorded during 30 years and analyse their epidemiological, anatomo-clinical, and therapeutic aspects. Patients could be classified as a function of site of fistula into 3 types, according to the Benchekroun's classification: type I ureto-vaginal fistula (30%); type II cervico-vaginal fistula (22%); type III vesico-vaginal fistula (48%). Etiology was mainly obstetrical (93%). An associated lesion was detected in 10.4% of cases (uterine, ureteral and rectal). Treatment was only performed after a minimal period of three months with the following results in obstetrical vesico-vaginal fistulas. Type I fistula, using a low approach and requiring urethral refection in 100 cases, showed good results in only 60% of cases. Type II fistulae, usually treated through a low approach (80%), were treated with 80% good results. Type III fistula, were nearly always corrected (98%) after two procedures. The overall results are good in 80% of cases. The failures concerned in majority the complex vesico-vaginal fistulas type I, are treated by urinary diversion (51 Coffey, 5 Bricker) and since 1975, 73 continent ileocecal or ileal bladders using Benchekrouns' technique.

Adolescent↗
PubMed1991

Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach.

The surgical management of rectovaginal fistulas complicating Crohn's disease has been associated with unacceptably high failure rates. We sought to modify the available surgical techniques to provide a solution to this challenging problem. Between December 1983 and January 1990, 14 patients with Crohn's disease underwent repair of a rectovaginal fistula. A modified transvaginal approach was employed by the authors. A diverting loop ileostomy was performed on all patients, either as the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. The fistula was completely eradicated in 13 of the 14 women and did not recur during the mean follow-up period of 55.0 months (range, 3-77 months). Intestinal continuity was reestablished in these 13 patients within 6 months after the initial fistula repair. One patient with a very low-lying fistula constituted our only failure. We have found the transvaginal method preferable to the transanal approach because of the relative ease in raising the vaginal flap as compared with a flap of fibrotic and inflamed anorectal mucosa. On the basis of this study, we conclude that a modified transvaginal approach is an effective method for repair of rectovaginal fistulas secondary to Crohn's disease.

Adult↗
PubMed1996

Vaginal misoprostol for induction of labor: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness and safety of the vaginal application of misoprostol for induction of labor at term, with the interval duration from labor induction to vaginal birth as the primary outcome measure. METHODS: Two hundred twenty-two women with indications for induction of labor at term were randomized to receive either misoprostol 50 micrograms per vagina every 4 hours as needed or our standard approach (physician-chosen combinations of intracervical or vaginal dinoprostone every 6 hours, artificial rupture of membranes, and oxytocin infusion). RESULTS: Mean (+/-standard deviation) time to vaginal delivery was 753 +/- 588 minutes for misoprostol versus 941 +/- 506 minutes for the physician-chosen combination (P = .018). Oxytocin infusion was used less frequently (relative risk [RR] 0.48, 95% confidence interval [CI] 0.31-0.74). There was no significant difference in cesarean rate or maternal morbidity. Neonatal outcomes, including cord-blood acid-base analysis, were not significantly different. The estimated cost per patient in Canadian dollars for prostaglandins was $0.22 with misoprostol and $70.00 with standard therapy. CONCLUSION: Vaginal misoprostol is a cost-effective alternative to current labor-induction protocols. We found no evidence of harm to mother or newborn in substantive outcomes.

Administration, Intravaginal↗