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PubMed2001

Vesicouterine fistula after vacuum delivery and two previous cesarean sections. A case report.

BACKGROUND: Vesicouterine fistulas are associated with cesarean section and more rarely with vaginal birth after cesarean (VBAC). Many surgical approaches exist, including hysterectomy. CASE: A vesicouterine fistula was diagnosed after VBAC in a 34-year-old multipara with two previous cesarean sections. The defect failed to close after four months of bladder drainage. Closure via laparotomy with an omental flap and preservation of the uterus was successful. CONCLUSION: Vesicouterine fistula can occur after VBAC, and failure of conservative therapy can be treated abdominally with preservation of the uterus.

Adult↗
PubMed2000

Analysis of the bleeding pattern in assisted reproduction cycles with luteal phase supplementation using vaginal micronized progesterone.

This study was designed to determine the effects of a vaginal micronized progesterone preparation on bleeding patterns and pregnancy outcomes after in-vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). The study population consisted of 149 consecutive women who had undergone IVF-ICSI using 'long-protocol' stimulation with buserelin-human menopausal gonadotrophin (HMG). A retrospective chart analysis of computerized medical records was undertaken. Vaginal progesterone (200 mg three times daily) was begun the day before oocyte retrieval and continued for a minimum of 16-19 days following human chorionic gonadotrophin (HCG) administration. Occurrence of bleeding following HCG injection, pregnancy rate and outcomes, and serum concentrations of oestradiol were measured. Women undergoing IVF and embryo transfer with ICSI and using vaginal progesterone for luteal support had normal luteal phase lengths (day of HCG minus day of onset of bleeding). In the absence of pregnancy, bleeding occurred after 19.2 +/- 3.9 days (mean +/- SD). Out of the pregnant group only three women bled within 19 days of HCG administration: two had biochemical pregnancies which spontaneously vanished and one evolved to term. The results reflect the normal bleeding pattern to be expected when vaginal progesterone is used for luteal support in IVF and embryo transfer, an approach whose efficacy has been amply proven. No shortened luteal phases were observed using vaginally administered progesterone.

Adult↗
PubMed1996

Laparoscopic total abdominal hysterectomy by suturing technique, with no transvaginal surgical approach: a review of 276 cases.

OBJECTIVE: To determine the effectiveness and safety of the new technique of laparoscopic total abdominal hysterectomy with prophylactic retroperitoneal rectovaginal-pouch of Douglas reconstruction and vaginal vault re-suspension by suturing method, with no transvaginal surgical approach. METHODS: The clinical prospective study included 276 women, and was conducted from July 1990 through December 1995. All women were subjected to a laparoscopic total abdominal hysterectomy with prophylactic retroperitoneal rectovaginal and pouch of Douglas reconstruction and vaginal vault suspension. The entire operation was executed via laparoscope with suturing and tying of extracorporeal sliding and intracorporeal two-turn flat square knot technique, and no transvaginal surgery was performed. The criteria for postoperative early (within 5 h) discharge plan were designed and assessed. RESULTS: All pre-planned instances of laparoscopic total abdominal hysterectomy with prophylactic retroperitoneal rectovaginal-pouch of Douglas reconstruction and vaginal vault re-suspension were completed; no technique failure was encountered. The average operating time for both hysterectomy and prophylactic surgery was 192 min. Intraoperative complications were two bladder injuries (0.72%); one case of inferior epigastric vessels injury (0.36%); one case of autologous, cells saver processed blood transfusion (0.36%). The immediate postoperative complications were four cases of voiding difficulty (1.45%) and five patients experiencing post anesthesia inordinate nausea and vomiting (1.81%). One patient required postoperative blood transfusion (0.36%). Delayed postoperative complications included 2 patients (0.72%) with superficial incisional skin infection. Estimated hemoglobin loss was from 0.5 g/dl to 5.0 g/dl, mean loss 1.5 g/dl. The extirpated uterine average weight 163 g. Postoperatively, within 24 h, 265 patients (96.01%) out of 276 were discharged home on the day of surgery, within 5 h, 110 patients (41.51%) out of 265 left the surgical unit. There was no single hospital post surgical re-admission. CONCLUSIONS: Laparoscopic total abdominal hysterectomy with prophylactic retroperitoneal rectovaginal-pouch of Douglas reconstruction and vaginal vault suspension by suturing method is a safe, well-defined operation, executed with no need for transvaginal surgical approach, and well accepted by patients.

Adult↗
PubMed2003

The tensile strength of uterosacral ligament sutures: a comparison of vaginal and laparoscopic techniques.

OBJECTIVE: To compare the tensile strength of two approaches for uterosacral ligament suturing using a cadaver model. METHODS: In 12 unembalmed cadavers, four polytetrafluoroethylene sutures were placed through the uterosacral ligaments. In each cadaver, two sutures were placed laparoscopically, and two more were placed vaginally. A single, experienced surgeon placed all laparoscopic sutures (n = 23), and another experienced surgeon placed all vaginal sutures (n = 22). A blinded team of investigators measured the distance from each suture to the ipsilateral ischial spine; determined whether any sutures incorporated ureters, viscera, or large vessels; and then passed the sutures through an apical vaginal incision. Using a hand-held tensiometer, progressive tensile load was then applied to these sutures along the axis of the vagina until they either broke or were completely dislodged from the ligaments. RESULTS: The average peak tension required to break or dislodge the sutures was 26.2 +/- 8.8 psi (laparoscopic) and 22.5 +/- 7.4 psi (vaginal) (P =.14, 95% confidence interval [CI] -1.2, 8.6). The average force required for suture breakage (n = 28) was 28 +/- 7 psi, and the average force applied when ligament failure occurred (n = 17) was 18.5 +/- 6 psi (P <.001, 95% CI -13.8, -5.2). The average distance from a laparoscopic or vaginal suture to the ipsilateral ischial spine was 19.1 +/- 7 mm and 17.4 +/- 6 mm, respectively (P =.46, 95% CI -3.0, 6.4). None of the sutures from either technique were found to incorporate a visceral structure, ureter, or great vessel. CONCLUSION: These suturing techniques appear to be equal in tensile strength.

Aged↗
PubMed1979

[Surgical treatment of prolapse of vaginal stump (author's transl)].

Prolapse of the vaginal stump, following hysterectomy, is relatively rare. Its treatment is not always gratifying for its high rate of recurrence. -- While there is a great number of proposed surgical approaches to prolapse, the author actually resorted to one vaginal and one abdominal method for his own surgical treatment of 24 patients with prolapse of the vaginal stump. The vaginal method was the one proposed by Symmonds and Pratt and the abdominal was promontory fixation. The latter method appeared to be the safest with regard to recurrence.

Adult↗
PubMed2001

Hysterectomy with bilateral salpingo-oophorectomy: a survey of gynecological practice.

BACKGROUND: Oophorectomy at the time of hysterectomy can be carried out by open and minimally invasive methods. The objective of this survey was to determine the current operative practice concerning oophorectomy at hysterectomy for benign gynecological disease in the UK, and to establish practitioners' views regarding the desirability of a randomized controlled clinical trial to compare various operative techniques for this procedure. SETTING: Gynecologists associated with the British Society of Gynecological Endoscopy. METHODS: A self-administered structured questionnaire was posted to 323 UK gynecologists to enquire about their surgical practice in performing oophorectomy at hysterectomy and their willingness to participate in a randomized trial. RESULTS: The postal questionnaire was returned by 147 (46% response rate). For performing oophorectomy at hysterectomy, 84 (57%) routinely used laparotomy only. However, 67 (46%) in total were competent in all surgical methods i.e. laparotomy, vaginal and laparoscopical. Of these, 38 (57%) were willing to enter patients into a proposed clinical trial comparing vaginal and laparoscopically assisted oophorectomy at hysterectomy. CONCLUSION: The current surgical approach to performing oophorectomy at hysterectomy varies widely. This suggests that opinion regarding the relative roles of abdominal, vaginal and laparoscopic methods is divided. Hence, a rigorous randomized trial comparing the efficacy and safety of these methods is practicable and urgently needed.

Aged↗
PubMed2005

A review of laparoscopic uterine suspension procedures for uterine preservation.

PURPOSE OF REVIEW: The most appropriate surgical approach for uterine preservation still remains the subject of ongoing controversy. Uterine suspension procedures can be performed abdominally, vaginally, or laparoscopically. This article focuses on the three different laparoscopic approaches of uterine suspension for uterine preservation: suspension to the round ligaments; suspension to the uterosacral ligaments; and suspension to the anterior ligament of the sacral promontory. This article reviews the published studies in the literature, analyzes the results, discusses the differences, and compares the different laparoscopic techniques. RECENT FINDINGS: A review of the literature reveals a paucity of research studies and publications on laparoscopic uterine suspension procedures. All the published studies are small, retrospective case series or case studies. Laparoscopic ventrosuspension using the round ligaments for uterine prolapse has a reported success rate of less than 50%. The ventrosuspension procedure has a very limited role and should not be employed. In comparison, laparoscopic uterine suspension procedures have a reported success rate ranging between 81 and 100%. The newest surgical technique is the laparoscopic sacral colpohysteropexy and there is only one reported case series on this procedure. The reported success rate for the sacral colpohysteropexy is 100%. SUMMARY: The first surgical option for uterine preservation is uterine suspension to the uterosacral ligaments. If the uterosacral ligaments cannot be identified or the uterosacral ligaments are weak and unusable, then laparoscopic sacral colpohysteropexy is a reliable second option. Uterine suspension to the round ligaments has an unacceptably high failure rate and is not an effective, durable alternative.

Adult↗
PubMed1993

Laparoscopic supracervical hysterectomy. A comparison of morbidity and mortality results with laparoscopically assisted vaginal hysterectomy.

Laparoscopic applications in hysterectomy promise to be a factor in decreasing both economic and medical morbidity. However, with the need for both advanced laparoscopic skills and good vaginal surgical techniques, the meaningful conversion rate (total abdominal hysterectomy to laparoscopically assisted vaginal hysterectomy) appears to be low. A less morbid approach may be subtotal hysterectomy, in appropriate candidates, particularly if this procedure is readily accomplished by an increased number of physicians. A comparison of outcomes in 50 laparoscopically assisted vaginal hysterectomy patients versus 50 laparoscopic supracervical hysterectomy patients was made, demonstrating that the subtotal procedure was significantly less morbid.

Adult↗
PubMed2003

Mucosal immunization with inactivated HIV-1-capturing nanospheres induces a significant HIV-1-specific vaginal antibody response in mice.

Mucosal secretory IgA is considered to have an important role in the prevention of human immunodeficiency virus type 1 (HIV-1) transmission through sexual intercourse. Therefore, substances that induce HIV-1-specific IgA antibody in the genital tract may become promising candidates for prophylactic vaccine against HIV-1 infection. We have previously reported that concanavalin A-immobilized polystyrene nanospheres (Con A-NS) could efficiently capture HIV-1 particles and gp120 antigens on their surface and that intravaginal immunization with inactivated HIV-1-capturing nanospheres (HIV-NS) induced vaginal anti-HIV-1 IgA antibody in mice. In this study, various strategies for immunization with HIV-NS were undertaken to induce HIV-1-specific IgA response in the mouse genital tract. HIV-NS were administered intravaginally, orally, intranasally or intraperitoneally to mice. Progesterone treatment enhanced the anti-HIV-1 IgA response to intravaginal immunization significantly, but intranasal immunization with HIV-NS was more effective compared with other immunization routes in terms of vaginal IgA response. In addition, vaginal washes from intranasally immunized mice were capable of neutralizing HIV-1(IIIB). Thus, application of HIV-NS is a practical approach to promote HIV-1-specific IgA response by the vaginal mucosa in the mouse and intranasal appears to be an effective immunization route in this animal model. Intranasal immunization with HIV-NS should be further pursued for its potential as an HIV-1 prophylactic vaccine.

AIDS Vaccines↗
PubMed1997

A technique of minilaparotomy-assisted vaginal hysterectomy.

In minilaparotomy-assisted vaginal hysterectomy, the operation begins vaginally by opening the peritoneal folds and ligating the uterine vessels and uterosacral ligaments. Minilaparotomy is then performed for myomectomy, cutting the fallopian tubes and the utero-ovarian ligaments and detaching any adhesions on the anterior peritoneal angle. In 26 women who underwent this procedure, the feasibility rate was 100% and no intraoperative complications or postoperative morbidity was observed (except in one case of ovarian bleeding), indicating that vaginal hysterectomy assisted by minilaparotomy is a feasible approach for hysterectomy in the setting of large myomas, myomas with adhesions caused by endometriosis or previous pelvic surgery, and adenomyosis.

Adult↗
PubMed1978

Alterations of male sexual behavior by learned aversions to hamster vaginal secretion.

Male hamsters poisoned after their first adult exposure to the vaginal secretion of female hamsters became hesitant to approach and ingest the secretion. The same aversion-training procedure also altered the responses of males to estrous females, changing the latency, frequency, and duration of a variety of behaviors that are commonly taken as indexes of sexual attraction or arousal and of copulatory performance. The effects suggest that the aversions to vaginal secretion alter the perceived meaning of the secretion for male hamsters, and analysis of the correlations between various measures of sexual arousal and performance support the hypothesis that separate mechanisms underlie the effects of the secretion on appetitive and consummatory sexual behavior.

Animals↗
PubMed2006

Prepubic and thigh abscess after successive placement of two suburethral slings.

We present a case of prepubic and thigh abscess after the placement of two types of suburethral slings in a 65-year-old woman suffering from stress urinary incontinence (SUI). The first surgical procedure (prepubic tension-free vaginal tape) was unsuccessful. Thus, 2 months later, we placed an ObTape sling by transobturator approach. This second procedure was successful. Seven months later, the patient presented with vaginal erosion of the sling with no inflammatory signs. The suburethral portion of the sling was immediately removed and the vagina was sutured. Nine months later, a prepubic abscess occurred and required removal of the prepubic sling, drain placement, and antibiotic therapy. Unfortunately, 9 months later, a thigh abscess occurred. Magnetic resonance imaging (MRI) allowed precise diagnosis and anatomic localization of the thigh abscess. Surgery consisted of opening and draining the abscess and removing the transobturator sling. At 6 months follow-up, no persistent inflammatory sign was observed on MRI, and SUI did not recur.

Abscess↗
PubMed2005

Hysterectomy: benefits of clinical performance indicators in the evaluation of healthcare facilities.

PURPOSE: The aim of our study was to verify, by applying clinical performance indicators, the quality of healthcare given to hysterectomy patients and the benefits on their adoption in healthcare facilities. METHODS: The different surgical approaches and indications for surgery were evaluated in 534 patients analysing postoperative short-term complications and triggered clinical performance indicators (CPIs). RESULTS: Surgery was performed by the abdominal (80.9%) and vaginal route (19.1%). Postoperative complication rate was 13.5% and CPIs were triggered 108 times overall: 42 in benign conditions (10.3%) and 30 in malignancy (23.4%) (p = 0.001). In patients operated on for benign conditions the different approaches, abdominal or vaginal, showed differences in postoperative period (p = 0.4). In 10.9% of malignant and in 2.9% of benign conditions hospital stay was triggered (p = 0.001). Vaginal surgery showed a shorter average stay than laparotomy (p = 0.001). CONCLUSION: The use of CPIs may determine a refinement of clinical performance with positive effects on health, patient satisfaction, postoperative morbidity hospitalisation and healthcare cost savings.

Adult↗
PubMed2006

Congenital vaginal obstructions: varied presentation and outcome.

Congenital obstructing lesions of vagina, hydrometrocolpos, and hematocolpos, present at a variable time during early childhood and adolescence to different medical and surgical specialties. Twenty-six cases presenting over an 18-years period (1987-2005) were divided into three groups; Group A: neonates (6), Group B: adolescents (18), and Group C: adults (2). Common presentations in neonates (Group A) were abdominal mass (5), neonatal sepsis (3), and respiratory distress (2); whereas abdominal pain (18), voiding dysfunctions (13), and backache (7) were prevalent in adolescents (Group B). Adults (Group C) presented with inability to consummate and infertility (2). Four patients received erroneous treatment; exploratory laparotomy (1) and appendectomy (3). Urinary symptoms and associated urinary abnormalities were present in more than 50% of cases, especially those with complex anomalies. Management included excision of imperforate hymen (16) and transverse vaginal septum (8) through perineal (20) and abdominoperineal approach (4). Patients with urogenital sinus (1) and cloacal malformation (1) had staged reconstruction at 2.5 years of age following preliminary vesicostomy and colostomy at birth. On follow up (range 1-15 years; mean 7) more than 60% patients have menstrual irregularity (11), endometriosis (5), and infertility (4). In conclusion, rarity and variable presentation of congenital vaginal obstructions can lead to delayed diagnosis and erroneous management. A high index of suspicion and cross-sectional imaging help in early diagnosis and associated renal anomalies. A comprehensive management is imperative to preserve the reproductive potentials, as significant proportion of patients may experience sexual difficulties, menstrual irregularity, and infertility.

Abnormalities, Multiple↗
PubMed2006

Vesicovaginal fistula and mesh erosion after Perigee (transobturator polypropylene mesh anterior repair).

The transobturator polypropylene mesh system is a new approach in the surgical treatment of anterior vaginal wall prolapse. We report the case of a 57-year-old woman who developed a vesicovaginal fistula with erosion of the mesh into the bladder and vagina after Perigee transobturator, polypropylene mesh anterior repair. This is a serious complication associated with this technique. Treatment required an open vesicovaginal fistula repair with excision of the exposed and nearby surrounding mesh.

Female↗
PubMed1999

The future of bacterial vaginosis-related research.

Various ways and criteria are used to diagnose BV. Guidelines should be redrawn and they should embody greater uniformity. The etiology of BV remains enigmatic. However, various observations suggest that host factors, possibly hormonal, cause an imbalance in the vaginal microflora. Exogenous factors, such as semen and antibiotics, may then help to bring about a more prolonged change. This forms a working hypothesis for further exploration. The role of the lactobacillus phage in the development of BV also needs to be determined. Various conditions may occur as a consequence of BV in non-pregnant and pregnant women and BV may also affect men. A subjective assessment of the extent to which these associations occur or are likely to be shown to occur by further investigations is presented in Table 1. The ability to cure acute BV needs to be improved as does the treatment of chronic BV, for which vaginal recolonization with exogenous lactobacilli is an approach to be evaluated further.

Female↗
PubMed1996

Avoiding the Space of Retzius During the Laparoscopic Burch Procedure

Although the structures apposed by a Burch colposuspension, the lateral vaginal fornix and Cooper's ligament, are approached surgically by opening the space of Retzius, neither actually lies in the space of Retzius but in the paravesical-paravaginal space. Cooper's ligament cannot be exposed adequately if the paravesical space is opened laparoscopically. Five primary Burch colposuspensions were performed without opening the space of Retzius, four with the uterus in place and one after a hysterectomy. Approaching the operation through the paravesical space has several advantages. A fixed anatomic landmark for the paravesical space is the umbilical ligament, and it can be easily identified laparoscopically. The paravesical space can be opened without risk of bladder injury. The urachus does not have to be divided. All the advantages of a transperitoneal approach are retained. Suture placement is greatly facilitated. Preliminary experience suggests that a laparoscopic Burch procedure can be carried out easily, quickly, and safely through the paravesical space, but this requires confirmation.

Journal Article↗
PubMed2002

Early-stage endometrial cancer: is intravaginal radiation therapy alone sufficient therapy?

For half a century, adjuvant radiation therapy has been an important component in the treatment of patients with early-stage endometrial cancer believed to be at significant risk of local or regional recurrence. The widespread adoption of up-front surgical treatment and staging, including nodal assessment, has raised new questions about the need for and extent of postoperative adjuvant treatment. Furthermore, in some institutions, even in the absence of complete surgical staging, the extent of postoperative adjuvant treatment is being reassessed. These developments have increased interest in the use of intravaginal brachytherapy (IVRT) alone in selected patients whose major risk of recurrence is at the vaginal cuff. The potential advantages of this approach include lower cost and decreased acute and late toxicity. The use of IVRT alone in select patients was examined through a review of the available literature. The authors conclude that there is a subset of patients in whom adjuvant treatment with IVRT alone is adequate. A clinical approach involving patient selection criteria is proposed which suggests separate selection criteria based on whether or not complete surgical staging information is available.

Endometrial Neoplasms↗