A longitudinal qualitative evaluation of patient perspectives of adverse events after pelvic reconstruction surgery’

A case of mesh erosion in the ureter eight years after a tension-free vaginal mesh surgery

Ventral-onlay buccal mucosal graft urethroplasty for the treatment of female urethral stricture: a step-by-step video for Female Pelvic Reconstructive Surgeons Abstract Introduction and hypothesis Female urethral stricture is a relatively uncommon disease. Conservative management with repeated urethral dilation often leads to unsatisfactory results. Although treatment of female urethral stricture with urethral reconstruction using a variety of surgical techniques is a surgical option, female pelvic reconstructive surgeons have limited exposure to these procedures in their training. The purpose of this video is to demonstrate a step-by-step ventral-onlay buccal mucosal graft urethroplasty in a patient with female urethral stricture disease. Methods We use a live action surgical video to describe the harvest of a buccal mucosal graft and ventral-onlay urethroplasty. Results This video provides a step-by-step approach to a ventral urethroplasty using a buccal mucosal graft. It can be used to educate and train those performing female pelvic reconstructive surgery. Conclusion Pelvic surgeons should be familiar with the management of female urethral stricture, including surgical treatment options such as urethral reconstruction. This video may be used to facilitate the reproducibility and comprehension of the ventral urethroplasty procedure.

Urethral diverticulum in pregnancy: a case report Abstract Introduction and hypothesis Urethral diverticulum in pregnancy is a rare finding and difficult to diagnose. The classical triad of dysuria, dyspareunia and dribbling of urine is found in a minority of women. Methods A young woman presented during the first trimester of pregnancy with vaginal and suprapubic pain as well as voiding difficulty. Ultrasound demonstrated a 2-cm hypoechoic lesion to the left of the urethra. She went on to have a cystoscopy that demonstrated a diverticulum. She was found to have chlamydia on PCR. Results Her pregnancy was complicated by recurrent admissions for pain and also an episode of reactive arthritis. She underwent an uncomplicated surgical excision postpartum. Conclusions Urethral diverticula should be excluded whenever a patient exhibits unresolved, nonspecific urinary problems. This is an underdiagnosed problem. Pregnancy presents additional challenges, but does not preclude medical or surgical treatment in the patient with significant symptoms.

Validation of the Arabic linguistic version of the 8-item overactive bladder questionnaire (OAB-V8) Abstract Introduction and hypothesis This study aimed to translate and validate the 8-item overactive bladder questionnaire (OAB-V8). Methods Utilizing a multistep process, the English version of the OAB-V8 was translated into Arabic by three urologists and one independent translator. It was validated by asking 46 patients with overactive bladder and 58 healthy individuals to complete the questionnaire. Healthy individuals were involved in establishing the discrimination validity. The scores of both groups were compared using the Mann-Whitney test. The reliability of the Arabic version was evaluated utilizing Cronbach’s alpha test for internal consistency. Spearman’s correlation coefficient (r) was utilized to evaluate the domain structures and the inter-domain associations. Results Internal consistency was high (Cronbach’s alpha = 0.923). There were good correlations among frequency, urgency, sudden urge to urinate, waking up at night to urinate and uncontrollable urge to urinate. There were weak or no correlations among urge, incontinence and nocturia. For discrimination validity, there were significant changes in all domain scores when comparing patients with ureteric stents and healthy individuals (P < 0.001). Conclusions The Arabic version of the OAB-V8 proved to be a reliable and valid tool, which can be easily utilized to evaluate symptoms in Arabic patients. It is feasible in evaluating quality of life in relation to this disorder, as patients are able to demonstrate their symptoms accurately with the comfort of their first language, Arabic.

Interposition of the mesorectal flap as prevention of rectovaginal fistula in patients with endometriosis Abstract Introduction and hypothesis Endometriosis is a gynecological condition characterized by endometrial tissue outside of the uterus. It affects up to 15% of women of reproductive age. In the case of bowel infiltration, about 90% of lesions are localized on the sigmoid colon or the rectum and may interfere with bowel function. Three surgical approaches are possible: (1) shaving technique, (2) discoid resection of the nodule, and (3) segmental resection with end-to-end anastomosis. A rectovaginal fistula is feared as a postoperative complication mainly in simultaneous resection of the vaginal and the rectosigmoid nodules. Its prevention is a two-step surgery (the first operation on the vagina and the second on the colon) or a preventive colostomy, both of which are often thought to be too invasive for a benign condition. Herein, we suggest a one-step surgery to prevent its development. Methods In three women, a concomitant laparoscopic resection of the vaginal and rectosigmoid endometrial nodule was completed with interposition of a mesorectal flap. Results All surgeries were uncomplicated with no rectovaginal fistula in the postoperative period. Conclusion In the hands of skilled surgeons, this one-step technique can be used to prevent rectovaginal fistula development.

Flow disruptions in robotic-assisted abdominal sacrocolpopexy: does robotic surgery introduce unforeseen challenges for gynecologic surgeons? Abstract Introduction and hypothesis The purpose of this study was to apply a human factors research approach to identify flow disruptions, deviations in the optimal course of care, in robotic abdominal sacrocolpopexy procedures with the ultimate goal of developing system interventions to improve the safety and efficiency of robotic surgery. Methods Twenty-four robotic abdominal sacrocolpopexy procedures were observed for flow disruptions. Surgeries were divided into four phases: (1) patient arrival and induction of anesthesia; (2) port placement and robot docking; (3) console time; (4) undocking of robot, incision closure, and patient exiting the OR. Results Flow disruptions were observed at a rate of 10.9 ± 5.1 per hour. The most frequently observed flow disruptions involved training issues (2.8 ± 2.4 flow disruptions per hour), equipment (2.2 ± 1.6 flow disruptions per hour), and poor coordination (2.0 ± 1.3 flow disruptions per hour). The rate of flow disruptions was highest in phase 2 (19.2 ± 14.4 flow disruptions per hour). Cases with more experienced surgeons involved shorter console times by 1.5 h (95% CI: 0.1, 3.0, p = 0.033) and 1.8 fewer (95% CI: 1.2, 2.6, p = 0.001) flow disruptions per hour. Surgeries were 1 h shorter on average (95% CI: 0.1, 1.9, p = 0.034) in cases in which the patient was > 65 years old. Da Vinci S console times were 0.8 h longer (95% CI: 0.01, 1.5, p = 0.047) than Si. Conclusions Flow disruptions in robotic abdominal sacrocolpopexy surgery occur about every 6 min. Flow disruption rates are highest during the most complex portions of the surgery. More experienced surgeons have lower flow disruption rates and operate more quickly.

Reconstruction of the urethra with an anterior vaginal mucosal flap in female urethral stricture Abstract Introduction and hypothesis We present our single institution experience with urethral reconstruction by using anterior U-shaped vaginal flap in female patients with urethral stricture. Methods Retrospective analysis was performed from March 2014 to April 2018. Fourteen patients with retention or severe voiding dysfunction and failed conservative management were enrolled. The demographic characteristics, vaginal examination, urodynamic parameters, and post-void residual urine (PVR) were reviewed. Patient Global Impression of Improvement (PGI-I) and American Urological Association (AUA) symptom index were completed pre- and post-operatively. In the dorsal lithotomy position, the Foley catheter was inserted and two parallel anterior vaginal walls incised around the urethral meatus. After dissection and the vaginal flaps were flipped up, the dorsal part of the urethra was incised vertically to pass the stricture and the distal end of the vaginal flap sutured to the proximal end of the urethra and inner part of the flap was tabularized over the larger size of Foley’s catheter. The second layer of the folded vaginal flap was sutured to native vagina. Results In all the patients, voiding LUTS improved or was cured. Average postoperative maximum urinary flow rate (Qmax) was 15.82 ± 3.27 ml/s and PVR was 27.35 ± 18.76 ml. During the follow-up, new onset of urgency and worsening urge incontinence were reported. Two patients suffered from stress urinary incontinence (SUI) after surgery, but in 1 patient it improved after 6 months and in the other due to the persistent SUI, trans-obturator tape (TOT) was applied after 12 months. Conclusions Most patients had a high level of satisfaction and improvement of lower urinary tract symptoms (LUTS). Hence, anterior vaginal flap urethroplasty is a safe and effective technique and may be utilized in the management of the initial phases of female urethral stricture after a multicenter prospective trial.

Turkish translation of the Prolapse and Incontinence Knowledge Questionnaire: validity and reliability Abstract Introduction and hypothesis To translate the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) into Turkish and test its validity and reliability. Methods The study included 341 women. The translation of the PIKQ, which comprised of the urinary incontinence (PIKQ-UI) and pelvic organ prolapse (PIKQ-POP) sections, was performed in accordance with international recommendations. The Incontinence Quiz (IQ) and the Visual Analog Scale (VAS) were applied to assess the level of knowledge about POP and UI. Psychometric analyses consisted of assessing the following: (1) construct validity by confirmatory factor analysis, (2) criterion and known group validity, (3) internal consistency reliability by the KR-20 coefficient, and (4) test-retest reliability over 1 week with the intraclass correlation coefficient (ICC). Results All fit indices except the Standardized Root Mean Square Residual indicated acceptable fit for the final models. Criterion validity was supported by moderate correlations between the PIKQ-UI and the IQ (rho = 0.679, p < 0.001). There were positive and weak linear correlations between the PIKQ-UI and PIKQ-POP scores and their corresponding perceived knowledge scores (rho = 0.351, p = 0.013 and rho = 0.345, p = 0.014, respectively). The known group validity did not show differences indicating that participants did not have enough knowledge about UI and/or POP even when they had the condition or acquaintance with them (p = 0.852 and p = 0.185, respectively). Reliability was excellent as indicated by the ICCs of 0.91–0.90, and KR-20 of 0.67–0.75 indicated good internal consistency for the PIKQ-UI and PIKQ-POP, respectively. Conclusions The Turkish version of the PIKQ is a valid and reliable instrument to assess the knowledge of UI and POP.

Development and validation of a protocol for documentation of obstetric perineal lacerations Abstract Introduction and hypothesis The aim of this study was to develop a new protocol for documentation of perineal lacerations and to validate the latter against the most common obstetric record system in Sweden. The hypothesis was that the new protocol would render more complete data on perineal lacerations than the current documentation method. Methods A protocol for documentation of perineal lacerations was developed to be sufficiently comprehensive to serve research purposes. All women delivering their first child vaginally from 13 October 2015 to 1 February 2016 at Örebro University Hospital were eligible for the validation study. Perineal lacerations were documented using the protocol in parallel with the regular obstetric record system (ObstetriX). Cross tabulations were used to compare the coverage regarding perineal lacerations between the two documentation methods. McNemar’s test was used to evaluate systematic differences between the methods. Results A total of 187 women were included. The coverage of documentation regarding perineal laceration was significantly higher (p < 0.001) in the new protocol (89%) compared with ObstetriX (18%). Incidence of second-degree perineal tears was 26% according to the new protocol and 11% according to ObstetriX. The incidence of third-degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according to the new protocol, and 3.2%, 2.7%, and 1.1% according to ObstetriX. Conclusions This validation study of a new documentation protocol showed that it delivered significantly more comprehensive information regarding perineal lacerations than the most common obstetric record system in Sweden.