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Surgical Technology International 29
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Surgical Technology International XXIX contains 49 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
October-2016- ISSN:1090-3941
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Gynecology
Transcutaneous Temperature Controlled Radiofrequency (TTCRF) for the Treatment of Menopausal Vaginal/Genitourinary Symptoms
Gustavo Leibaschoff, MD, Specialist, Gynecology and Obstetrics Department, University of Buenos Aires School of Medicine, Buenos Aires, Argentina, Pablo Gonzalez Izasa, MD, Specialist, Gynecology and Obstetrics Department, Military University of Colombia, Head Chief, Urogynecology Department, Hospital Universitario San Jorge, Pereira, Colombia, Jose Luis Cardona, MD, Specialist, Pathology Department, Universidad Tecnologica, Pereira, Colombia, John R. Miklos, MD, Specialist, Female Pelvic Medicine and Reconstructive Surgery Department, International Urogynecology Associates of Atlanta, Beverly Hills, California and, Dubai, United Arab Emirates, Professor, Obstetrics and Gynecology Department, Emory University, Atlanta, Georgia, Robert D. Moore, DO, FACOG, FPRMS, FACS, Specialist, Female Pelvic Medicine and Reconstructive Surgery, International Urogynecology Associates of Atlanta, Beverly Hills, California and Dubai,, United Arab Emirates, Professor, Obstetrics and Gynecology Department, Emory University, Atlanta, Georgia
772
1-09-2016
Objective: The aim of this study was to evaluate the effects of non-ablative, monopolar transcutaneous temperature controlled radiofrequency (TTCRF) technology in the treatment of postmenopausal women suffering from genuine stress urinary incontinence (SUI) related to menopause and to evaluate histological changes vaginally associated with the treatment.
Materials and Methods: Subjective and objective symptoms of SUI were assessed in study subjects before and after TTCRF, (1 treatment every 30 days, for 3 months; n=10) and compared with the effects of a placebo treatment on a control group of demographically similar women (n =10). SUI was subjectively evaluated with subjective Urogenital Distress Inventory (UDI-6) and with the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) before and after TTCRF treatments and objectively with cough stress test. Vaginal health was evaluated with the Vaginal Health Index (VHI) score and visual analogue score (VAS) for dyspareunia and dryness. Punch biopsies were obtained at the urethra-vesical junction in the anterior compartment, before and at the end of the treatment protocol. Basic and histochemical staining methods were used.
Results: In subjects suffering SUI, TTCRF treatment was associated with a significant (p< 0.01) improvement of ICIQ-SF and UDI-6 scores. Seven of 10 patients (70%) had a negative cough stress test after the treatment protocol. Improvements were maintained up to the 12th week of follow-up. The results were supported by the positive histologic changes seen vaginally in women suffering from postmenopausal vaginal atrophy. TTCRF was well tolerated with no complications reported in study patients.
Conclusion: TTCRF treatment in postmenopausal women suffering from SUI showed significant improvement in both objective and subjective symptoms. Vaginal health scores also improved as did VAS for dryness and dyspareunia. We feel these improvements were related to histological changes related to improvement in vaginal atrophy that were not observed in placebo patients.
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Post-Ablation Endometrial Carcinoma (PAEC) Following Radiofrequency Endometrial Ablation: A Case Report and Its Implications for Management of Endometrial Ablation Failures
Morris Wortman, MD, FACOG, Director, Center for Menstrual Disorders, Clinical Associate Professor of Gynecology, University of Rochester Medical Center, Rochester, New York, Josette C. Dawkins, MD, Resident, Second Year, Obstetrics and Gynecology, Rochester General Hospital, Rochester, New York
773
12-07-2016
Endometrial ablation (EA) has become one of the most commonly performed gynecologic procedures in the United States and other developed countries. Global endometrial ablation (GEA) devices have supplanted resectoscopic ablation primarily because they have brought with them technical simplicity and unprecedented safety. These devices, all of which received FDA approval between 1997 and 2001, are typically used to treat abnormal uterine bleeding (AUB) in premenopausal women. Several million women in the US who have undergone a previous EA procedure are about to enter the risk pool for the development of endometrial cancer (EC). Ours is the 18th reported case of post-ablation endometrial carcinoma (PAEC) in the English literature. This case underscores the diagnostic challenges faced in evaluating women with a history of a previous EA who cannot be properly evaluated with conventional techniques such as endometrial biopsy and sonohysterography.
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The Indication and Surgical Treatment of 286 Midurethral Synthetic Sling Complications: A Multicenter Study
Orawee Chinthakanan, MD, MPH, International Urogynecology Associates, Atlanta, Georgia and Beverly Hills, California, Clinical Instructor, Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, John R. Miklos, MD, Director, International Urogynecology Associates, Atlanta, Georgia and Beverly Hills, California, Robert D. Moore, DO, Director, Advanced Pelvic Surgery, Atlanta, Georgia, Deborah R. Karp, MD, Assistant Professor, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia, Gladys M. Nogueiras, MD, Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, Florida, G. Willy Davila, MD, Chairman, Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, Florida
794
1-10-2016
Introduction and Hypothesis: 1) Evaluate the most common indication for sling removal in patients with synthetic mesh slings; 2) identify the location of pain for each of the three types of synthetic sling procedures including retropubic (RP) sling, transobturator (TOT) sling, and single incision slings (SIS), and 3) describe the surgical approach to each of the above and its associated complications.
Materials and Methods: A retrospective chart review of all patients who underwent surgical removal of a sling due to a mesh-related complications from 2011 to 2013 at three referral centers.
Results: There were 337 sling complications followed by the IUGA/ICS mesh complication classification. RP slings were more likely to have urinary tract complications (category 4) and intra-abdominal site complications (S5). Of those, 286 slings were removed, 106 (37.1%) were RP, 131 (45.8%) TOT, and 44 (15.4%) SIS. Vaginal pain was the most common reason for sling removal. Twenty-one percent of the TOT had groin pain which was a five times higher risk than RP (OR 5.3, 95% CI 1.5–18.7), and the RP was three times more likely to have suprapubic pain than the TOT (OR 2.97, 95% CI 1.3–7.0). Fifteen percent of the TOT had either unilateral or bilateral groin mesh removal.
Conclusion: The most common indication for sling removal was vaginal pain. RP sling had a higher risk of suprapubic pain and TOT sling had a higher risk of groin pain. Patients with a history of SIS had a higher incidence of urethral erosion. TOT removal had the highest intraoperative complication rate.
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Biosurgicals and the Minimally Invasive Gynecologic Surgery (MIGS) Surgeon
James Dana Kondrup, MD, Assistant Clinical Professor, Obstetrics and Gynecology Department, Upstate Medical Center, Binghamton Campus, Binghamton, New York, Frances R. Anderson, PhD, RN, Research Coordinator, Nursing Administration, Our Lady of Lourdes Memorial Hospital, Binghamton, New York, Melanie Rose Katz, MS IV, Medical Student, SUNY Upstate Medical Center, Syracuse, New York
678
25-09-2016
Biosurgical materials (biosurgicals) have a wide array of uses for providing hemostasis, including decreasing the risk of postoperative bleeding and, intraoperatively, controling bleeding. These materials are especially useful in situations where electrocautery, sutures, or clips are not feasible. Biosurgicals have long been used in general surgery and surgical subspecialties to provide hemostasis; however, they still are not commonly used during obstetric and gynecologic procedures.
Three commonly used classes of biosurgicals will be discussed in this article: oxidized regenerated cellulose, flowables, fibrin sealants, and fibrin sealant patches. Each of these agents has a different role to play during minimally invasive gynecologic surgery (MIGS), either singularly or in combination with each other. One unique fibrin product is a fibrin sealant patch, which is a combination of products used to treat bleeding of various intensities, including acute, severe hemorrhagic situations.
It is important for the MIGS surgeon to understand the nature and use of each product to be able to use biosurgicals appropriately for hemostasis management. This article reviews biosurgical products, their composition, and application in minimally invasive gynecologic surgery. Included will be a few of the “on label�? and “off-label�? uses of biosurgicals—either singularly or in combination—and tips for introducing these materials during MIGS procedures.
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Laparoscopic Hemi-hysterectomy and Trachelectomy in a Case of Herlyn-Werner-Wunderlich Syndrome
Entidhar Al Sawah, MD, Obstetrics and Gynecology Resident, Shayne M. Plosker, MD, Professor and Chief, Division of Reproductive Endocrinology and Infertility, Emad Mikhail MBChB, MD, FACOG, Assistant Professor, Minimally Invasive Gynecologic, Surgeon, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
755
20-06-2016
Background: Herlyn-Werner-Wunderlich Syndrome (HWWS) is a rare Müllerian anomaly characterized by uterus didelphys coexisting with an obstructed hemivagina and ipsilateral renal agenesis.
Case: A 13-year-old female presented one-year after menarche with severe dysmenorrhea and a right-sided pelvic mass. Imaging identified a right uterus with hematometra, hematocolpos, absent right kidney, normal left kidney, ureter, left uterus, and vagina compressed to the left by right hematocolpos. We performed laparoscopic hemi-hysterectomy of the non-communicating hemi-uterus, and laparoscopic trachelectomy.
Conclusion: Laparoscopic hemi-hysterectomy and trachelecotmy is a minimally invasive surgical option for patients with Herlyn-Werner-Wunderlich Syndrome.
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Indications and Complications Associated with the Removal of 506 Pieces of Vaginal Mesh Used in Pelvic Floor Reconstruction: A Multicenter Study
John R. Miklos, MD, Director, International Urogynecology Associates, Atlanta, Georgia and Beverly Hills, California, Orawee Chinthakanan, MD, MPH, International Urogynecology Associates, Atlanta, Georgia and Beverly Hills, California, Clinical Instructor, Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, Robert D. Moore, DO, Director, Advanced Pelvic Surgery, Atlanta, Georgia, Co-Director, International Urogynecology Associates, Atlanta, Georgia and Beverly Hills, California, Deborah R. Karp, MD, Assistant Professor, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia, Gladys M. Nogueiras, MD, Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, Florida, G. Willy Davila, MD, Chairman, Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, Florida
795
3-10-2016
Study Objective: Synthetic mesh utilized to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can often result in postoperative complications. The objectives of this study were to determine: 1) the most common indications for mesh removal; 2) the incidences of the removal of specific mesh procedures (such as suburethral sling [SUS], transvaginal mesh [TVM], or sacrocolpopexy); and 3) the idences and types of surgical complications associated with mesh removal.
Design: This was a retrospective study.
Design Classification: Canadian Task Force II-3.
Setting: Three tertiary referral centers in the United States.
Patients: We examined data from all patients at the three centers who underwent surgical removal of synthetic materials from previous SUS, TVM, and sacrocolpopexy procedures for mesh-related complications from 2011 to 2013.
Intervention: Patients underwent vaginal, intra-abdominal, and inguinal mesh revisions by cutting, partial removal, or total removal of the mesh for mesh-related complications.
Measurements and Results: Overall, 445 patients with complications underwent mesh removal laparoscopically, via groin dissection and/or transvaginally. There were a total of 506 mesh products removed. Of these, 56.5% were slings and 43.5% were for pelvic organ prolapse (POP). Synthetic mesh removed from patients included: transvaginal mesh (TVM) anterior for anterior vaginal prolapse, TVM posterior for posterior vaginal prolapse, sacrocolpopexy mesh, and suburethral slings (SUS) for stress urinary incontinence. Synthetic SUS removed included: retropubic (RPS), transobturator (TOT), and single-incision slings (SIS). TOT was the most common type of sling removed. Patients with a sling who only complained of vaginal pain with or without intercourse underwent a vaginal approach for surgical revision/removal of the sling (86.6%). Patients with an RPS with lower abdominal/suprapubic pain and vaginal pain underwent a vaginal and laparoscopic approach for sling removal (18.4%). Patients with a TOT sling who complained of vaginal and groin pain underwent a vaginal and inguinal approach for sling removal (4.3%). In patients who had POP mesh removal, 42.3% had an anterior TVM, 30.6% had a posterior TVM, 14% had both anterior and posterior TVMs, and 13.1% underwent sacrocolpopexy mesh removal. Complications encountered during mesh revision/removal surgery were: two blood transfusions from complete RPS removal (vaginal and laparoscopic approach), three urethral injuries during TOT sling removal (vaginal approach), two ureteral injuries during anterior vaginal wall mesh removal, and two rectal injuries during posterior vaginal wall mesh removal. All injuries were repaired at the time of mesh removal without recurrence.
Conclusion: In our study, the most common indication for mesh removal was pain with or without intercourse. The most common mesh procedure resulting in removal was the TOT sling. Use of a vaginal approach only for sling removal had the lowest incidence of intraoperative complications. Laparoscopic RPS removal had the highest incidence of required blood transfusions, anterior TVM had the highest incidence of ureteral injury, and posterior TVM had the highest incidence of rectal injury. Overall, sling, TVM, and sacrocolpopexy mesh removal are safe procedures when performed by experienced surgeons.
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