Modern approaches to the treatment of genital prolapse in obese women

Introduction. The problem of female genital prolapse (GP) remains in the sportlight of gynecologists, because despite the variety of surgical methods, there are still recurrences of the disease, which are associated not only with the failure of the restored ligaments, fascia, muscles, damaged pelvic floor and perineum, but with the imperfection of the operation. The solution of this problem is especially important in the treatment of patients with extragenital pathology, in particular obesity. The purpose: to optimize the treatment of genital prolapse in obese patients by determining an individual approach to planning surgical treatment taking into account the degree of obesity and concomitant pathology. Materials and methods. We examined 65 patients of which 20 had genital prolapse and obesity (main group), 25 had genital prolapse and normal weight (comparison group), 20 women did not have gynecological diseases and extragenital pathology made up control group. To diagnose obesity and determine its degree we calculated body mass index (BMI). To determine the degree of GP its quantitative assessment was used (POP-Q; 1996). Surgical intervention included transvaginal extirpation of the uterus without appendages, anterior colporrhaphy, colpoperineoraphy with levatoplasty, sacrospinal colpopexy. Transabdominal and laparoscopic colposacropexy in obese women were not used due to the presence of relative contraindications for laparoscopy (cardiovascular disease, respiratory pathology, adhesions, the condition after hernias’ surgery). Therefore, all operations on women with GP and obesity were performed transvaginally due to the inability to perform abdominal access. In comparison group transvaginal surgery was performed. All the groups under study were representative. Before the use of polypropylene mesh "Polymesh" to minimize purulent-septic complications associated with the use of synthetic prostheses aquadissection was performed with 0.9% saline with the addition of 1 g of ceftriaxone per 200 ml. After the operation, the women used suppositories with hyaluronic acid (revitax). Results. The results of surgical treatment have been analyzed and the following data were obtained: recurrences in the main and in the comparison group were 4% (2 women in whom operations were performed with the use of their own tissues without mesh prosthesis). Infectious complications, dyspareunia and pelvic pain were not observed. Conclusions. Surgical treatment of GP in obese women by using polypropylene mesh "Polymesh" for colposacropexy after transvaginal uterine extirpation increases the effectiveness of treatment and redduces the number of recurrences. Hydropreparation of the mesh with an antibacterial agent and postoperative use of hyaluronidase intravaginally helps to reduce purulent-septic complications of surgery and improves the patients’quality of life.

Vaginal Natural Orifice Transluminal Endoscopic Surgery for Gynecologic and Gynecologic Oncology Procedures

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an exciting new procedure that combines the best of laparoscopic and transvaginal surgery. The skills of a laparoscopic surgeon are applied to this approach which offers several advantages over traditional laparoscopy. First, the recovery of a vaginal procedure is shorter and less painful. Second, there is no abdominal incision which avoids potential for wound infection, herniation, pain and unsightly scarring. Third, the surgeon is seated with more comfortable ergonomics than traditional laparoscopy. Fourth, the blood supply is controlled very early in the procedure reducing overall blood loss. Fifth, the specimen for removal is quite close to the operator which enables less crossing of instruments and allows larger scopes with better illumination to be used. Finally, where traditional laparoscopy progresses to a smaller and smaller surgical area as the operation proceeds deeper into the pelvis, vNOTES is continually moving out of the pelvis with greater room for specimen manipulation and visualization. Advantages over traditional transvaginal surgery include the ability to examine the entire abdomen, the safety of direct visualization of the pedicles for adnexal removal, and the ability to perform abdominal procedures including lymph node removal, omentectomy, appendectomy, and biopsies not previously available to the vaginal approach.

Transvaginal repair of ureteral transection post gynecological surgery: a case report

Introduction: Ureteral injuries are relatively common in gynecological procedures. The repair of such injuries has traditionally been done through open surgery; however, minimally invasive techniques have become an option in some cases. We report the case of a ureteroureteral anastomosis successfully transvaginally approached. Case report: a 70-year-old woman developed hydronephrosis and acute renal failure after vaginal hysterectomy, parametrectomy, McCall culdoplasty, sacrocolpopexy, posterior colpoplasty and perineoplasty. She was reoperated, and had bilateral ureteral injuries correctly identified and repaired through the vaginal route. Discussion: Difficulties encountered during transvaginal surgery include ureter identification and the narrow surgical field. In order for a vaginal repair to be performed, surgeons must have expertise with vaginal surgery and know the anatomy of the ureter as seen through the vagina. Additionally, JJ stents can be used to facilitate repair. Conclusion: Vaginal repair of ureteral injuries is feasible and has potentially less morbidity than the standard abdominal approaches, but further studies are needed in order to determine its efficacy and complication rates.

Choosing the right sling for your patient

Recent data has demonstrated a one in five lifetime risk of a woman requiring stress urinary incontinence (SUI) surgery. Currently, most women opt for a synthetic midurethral sling (MUS), with over 3.6 million placed worldwide. This article attempts to identify whether a gold standard exists with regards to surgical correction of female SUI.When considering which sling type to use for which incontinent woman, the published data demonstrates excellent results for both synthetic mesh (retropubic or transobturator routes) and fascial pubovaginal slings for most patients. Intrinsic sphincter deficiency does appear to be better treated with the use of a retropubic approach, although still with less than stellar results. With little to differentiate, the treatment of most female SUI may be solely based on which sling the surgeon feels most comfortable performing. Currently, most urologists and gynecologists favour synthetic MUS over fascial slings in surgical-naïve patients; however, recent U.S Food and Drug Administration (FDA) warnings concerning the use of mesh in transvaginal surgery have patients questioning the safety of synthetic MUS for the treatment of SUI.