Liza D. L?e, MD

• Clinical Instructor
• Department of Emergency Medicine
• Temple University School of Medicine
• Philadelphia, Pennsylvania

In general bacteria 600x noroxin 400 mg buy mastercard, hernia occurs when a rupture in the smooth muscle or connective tissue allows a bodily structure to protrude antibiotics medicine purchase noroxin 400 mg with visa. An enterocele is usually referred to as a herniation through or into the vagina typically as a posterior enterocele antibiotics in poultry order noroxin 400 mg line, which develops in the rectovaginal space (pouch of Douglas or cul-de-sac) virus alive noroxin 400 mg purchase without prescription. The anterior enterocele in the vesicovaginal space is a rare entity [1] infection quest wow noroxin 400 mg order with amex, which might occur after cystectomy or after hysterectomy [2]. An enterocele is a form of pelvic organ prolapse with the bowel protruding into the vagina. Why and how are etiological and pathophysiological issues which are illustrated in this chapter. Surgical treatment of an enterocele is often concurrent or identical to operations for vaginal vault prolapse. Therefore, the pouch of Douglas is an anatomical structure that plays an important and probably predisposing part. The pouch of Douglas is normally closed and does not contain intestine or omentum. In anatomy textbooks, the extent of the pouch of Douglas has traditionally been described as 2­3 cm below the uterosacral ligaments. Histological studies by Uhlenhuth and colleagues have demonstrated that in the fetus the pouch of Douglas may extend to the perineal body [3]. The consecutive fusion of the anterior and posterior peritoneum forms the rectovaginal septum and determines the depth of the pouch of Douglas [3­5]. According to Uhlenhuth, the rectovaginal septum is distinguishable from the "fascial" capsule of the vagina and rectum. In contrast to anatomy textbooks, intra-abdominal measurements of the depth of the pouch of Douglas in young nulliparous women revealed great variations with 25%­75% of the posterior vaginal wall covered with peritoneum [6]. The mean depth of the pouch of Douglas was 49% of vaginal length in nulliparas, 46% in parous women, and was significantly deeper (72%) in patients with posterior vaginal wall prolapse. It would appear that the deep pouch of Douglas is frequently present in young nulliparous women without pelvic organ prolapse, which implies a congenital variation and predisposition [6]. A sophisticated concept of normal pelvic organ support accentuates the imperative role of several factors including integrity of the anterior and posterior endopelvic fascia with intact attachments as well as normal tone, position, and functionality of the levator ani muscle. Normal pelvic floor muscle and fascial structures are required to hold the perineum in place and ensure normal bladder, bowel, and sexual function. It is apparent that fascial defects in the three levels of vaginal support and the posterior compartment may contribute to pelvic organ prolapse including enteroceles [7,8]: the normal pelvic floor tone is essential for the nearly horizontal axis of the vagina, which in turn is necessary to allow for a normal pelvic floor protecting intra-abdominal pressure distribution. Intra-abdominal measurements of the depth of the pouch of Douglas have shown that in women with posterior vaginal 1268 wall and anterior rectal wall prolapse the pouch of Douglas is significantly deeper and may reach the level of the perineal body [6]. In addition, the anatomy of the pouch of Douglas is considerably different, which is a recognized feature in some studies. In women with severe pelvic organ prolapse, a large or voluminous rectovaginal pouch was a consistent anatomic finding, requiring obliteration during pelvic reconstructive surgery [9­11]. Apart from a mobile vaginal axis and a dehiscence of the levator hiatus, French authors reported a "grande fosse pelvi-périnéale"-a large pelvic pouch-to be the principal lesion in women with enteroceles [12]. Other authors described this phenomenon as an abnormally deep and wide cul-de-sac with a 3D enlargement [13]. Although different positions and courses of the sigmoid colon and its mesentery are known [14], systematic descriptions in women with pelvic organ prolapse are scarce. Baessler and Schuessler found 64% of women with enteroceles and all women with anterior rectal wall procidentia to have these features, termed as "grande fosse pelvienne. Given these findings, it seems reasonable to regard a deep pouch of Douglas as a risk factor for enterocele formation. An enterocele can only develop when other factors open and expose the deep pouch of Douglas. Normal pelvic floor support prevents opening and exposure of the pouch of Douglas. Vaginal Axis In a woman with normal pelvic organ support, the pouch of Douglas is closed, irrespective of its depth, and lies nearly horizontally between the levator plate and the vagina [16­18]. It is known that operations that change the vaginal axis can lead to increased prolapse in the "unprotected" area. This is true for the higher incidence of cystoceles after sacrospinous fixations, where the position of the vagina is more posterior and also for the considerate rate of rectoceles and enteroceles after Burch colposuspensions or ventrofixations where the vagina is displaced anteriorly. A deep pouch of Douglas is likely to accentuate the process of enterocele development once the vaginal axis is changed. Endopelvic "Fascia" the integrity of the anterior and posterior endopelvic fascia or connective tissue and its attachments is essential for normal pelvic organ support [8]. A defect in the endopelvic fascia or insufficiency is necessary for an enterocele to protrude. It is not entirely apparent whether the endopelvic fascia is identical to the rectovaginal septum as the latter can be rather short [20], depending on the depth of the pouch of Douglas. Whole-thickness biopsies of the leading edge of radiologically proven enteroceles showed that in none of the 13 women examined the vaginal epithelium was in direct contact with the perineum and all had a well-defined vaginal wall muscularis [21]. These findings add to the ongoing controversy on whether the fascia exists or not. It has been suggested that it is a structure that is artificially created during surgical dissection. This debate is complicated by inconsistent histological studies, some of which do not substantiate the concept of a fascia between the rectum and vagina. Whether the fascia is part of the vagina or rectum or whether it is a separate structure is of scientific but not clinical value. Fascia in the clinical sense means connective tissue that has tensile strength and is strong enough to hold sutures and support the underlying organs. These photos demonstrate a nearly normal position of the perineum at rest (a) but a "ballooning" of the perineum on straining (b). This patient had a large rectoenterocele that did not protrude outside the introitus. This stain is used to differentiate fibrous tissue (green) and smooth muscle (red). Note the amount of smooth muscle, organized connective tissue, and areolar tissue. Apart from bowel symptoms, which can be similar to complaints of patients with rectoceles or enteroceles, excessive perineal descent of more than 2 cm (measured in relation to the ischial tuberosities) is seen more frequently in women with posterior vaginal wall prolapse [24]. Solitary rectal ulcer, rectal prolapse, and intussusception are common concomitant findings [24,25]. The etiology is unclear, but reduced pelvic floor tone [26] with insufficient perineal and endopelvic fascial attachment and a deep pouch of Douglas and sigmoid colon elongation have been discussed. The term "ballooning" is also used to describe an enlargement of the genital hiatus during straining on perineal 3D ultrasound and is associated with pelvic organ prolapse [27]. Pulsion, Traction, Sliding, True, and Congenital: Concepts of Enterocele Development There are different concepts, and each one of them might be true in an individual patient. It is argued that a 1271 traction enterocele is accompanied by the loss of pelvic organ support [17] and a greater vault descent with normal anatomical connections between the pouch of Douglas and vagina [28,29]. In contrast, according to Nichols and Genadry [17], a pulsion enterocele is secondary to increased abdominal pressure, whereas Zacharin states that a pulsion enterocele occurs as a late complication of pelvic surgery like hysterectomies and is associated with a large rectovaginal pouch [28]. However, Zacharin is convinced that the depth of the pouch of Douglas has no bearing on enterocele development. He considers levator incompetence and relaxation of the fascial support to be the primary defects. In theory, an enterocele can only develop when important anatomical factors change: the vagina becomes more vertical and the (deep) pouch of Douglas opens or the pubocervical and rectovaginal fascia are separated. Whether a discrete defect in the endopelvic connective tissue is also required remains a topic for discussion. Rectal Prolapse Colorectal surgeons view prolapse with a different attitude but have similar problems defining the pathophysiology of rectal prolapse, which might originate from the pouch of Douglas [30]. Altemeier described three types: type 1 is a false prolapse due to mucosal redundancy, type 2 is an intussusception without an association with the pouch of Douglas, and type 3 is a sliding hernia of the rectovaginal pouch [31]. Enteroptoses, or elongation of the rectosigmoid colon, are considered contributing factors [32]. Further Factors Old textbooks often quote other factors that might contribute to enterocele formation. Apart from established confounders for pelvic organ prolapse like aging, obesity, and constipation with excessive defecatory straining, connective tissue diseases, parity, and malnutrition especially in war times are also mentioned [33]. Obesity and constipation have been established as risk factors for pelvic organ prolapse [35­37]. A chylous ascites has been described to accentuate pelvic floor defects and cause an enterocele [38]. The classical example is the development of enteroceles after Burch colposuspension in up to 32% [39­41], which has not been described for suburethral tapes. It has also been recognized that enteroceles and rectal prolapse frequently coexist with other defects of pelvic floor support [42­44]. In a prevalence study of 639 women aged 45­85 years using the pelvic organ prolapse quantification of the International Continence Society, only 22% had no prolapse at all, 37% had stage 1, 29% had stage 2, 9% had stage 3, and 3% had complete eversion [45]. Unlike a cystocele or rectocele, an enterocele does not appear to cause any stereotypical and pathognomonic symptoms, and very often symptoms cannot be distinguished from those of any coexisting pelvic organ prolapse. Some women primarily complain of rectal symptoms like fullness and 1272 incomplete or difficult bowel emptying; however, in others, the prolapse symptoms are predominant [46]. Anorectal symptoms and degree of posterior prolapse do not seem to correlate [47,48]. Partial or complete obstruction of the urethra might result in voiding difficulties or retention [49,50]. Dyspareunia, "slackness at intercourse," vaginal dryness, and coital incontinence are frequently reported by women with pelvic organ prolapse [51]. Mainly, a complication of previous pelvic floor surgery and hysterectomy, vaginal rupture, and evisceration has been reported in women with enteroceles [52]. Simultaneous bimanual examination of the tissues between the vagina and rectum under straining or in the standing position usually helps. An enterocele can be located in the anterior vaginal wall where it divides the pubocervical fascia in the posterior vaginal wall through the pouch of Douglas or it might separate the anterior and posterior endopelvic fascia at the vaginal vault (apical enterocele). Occasionally, peristalsis of the intestine bulging into the vagina establishes the diagnosis. If in doubt and a diagnosis is necessary, intraoperative evaluation during dissection will ascertain the presence or absence of an enterocele. However, perineal ultrasonography has gained popularity and has become the investigation of choice. Perineal ultrasound may depict an enterocele [53], especially when performed in an upright position. But even with conventional 2D perineal ultrasound, an enterocele can be identified. Rectal ultrasound can also be helpful; sonographic diagnosis of an enterocele was confirmed intraoperatively in 27 of 29 cases in one study [56]. Viscerography or fluoroscopic imaging includes the opacification of the bladder, rectum, and vagina with contrast medium. Ideally, the investigation is performed dynamically during straining or coughing and comprises defecography. It will also provide further 1273 information on bowel emptying, rectal prolapse, or intussusception [47,57] although there are great variations of "normal" findings. It is therefore most valuable when the clinician performs the radiological investigations and interprets the findings in context with the symptoms. Defecation in this situation might be impossible for some patients, and for the diagnoses of enteroceles, it may be inferior to defecating fluoroscopy studies [59]. Controlled studies assessing prevention of enteroceles are scarce but support modified McCall sutures with reattachment of the uterosacral ligaments to the vaginal vault during hysterectomy [61]. At the time of hysterectomy, Cruikshank and Kovac compared three available methods to prevent an enterocele in a randomized controlled trial [62]: obliteration of the pouch of Douglas by suturing the uterosacral ligaments in the midline, called the vaginal Moschcowitz-type operation; the McCall-type culdoplasty, where the uterosacral ligaments are plicated and attached to the vaginal vault and the sutures externalized; and the closing of the peritoneum with a purse-string suture. Up to 3 months 1274 postoperatively, all procedures were equally successful (100%). After 3 years, the McCall-type method was found to be superior for enterocele prevention with none of the 32 patients developing a symptomatic enterocele [62]. The prevention of an enterocele after a Burch colposuspension with or without additional pouch of Douglas obliteration by either approximation of the uterosacral ligaments or Moschcowitz-type horizontal purse-string sutures was reported recently [39]. Without Douglas obliteration, postoperative enterocele formation after 3­16 years (mean 9 years) occurred in 19%, whereas after the additional Moschcowitz procedure the incidence was 11% and after uterosacral ligament plication 2%. Whether extensive distal preparation of the bladder during abdominal hysterectomy with exposure of the pubocervical fascia might contribute to the development of anterior enteroceles is unclear. Also, the utilization of intrafascial hysterectomy might be of value but this has not been assessed systematically. During intrafascial hysterectomy, parts of the endopelvic fascia are maintained in their normal position and plicated over the vaginal vault to prevent separation and subsequent enterocele formation. Conservative treatment of 1275 pelvic organ prolapse in general includes the use of pessaries [63] and pelvic floor muscle training [64]. Vaginal pessaries might prevent deterioration of the prolapse and alleviate symptoms of prolapse and are especially useful if there is a long waiting list for surgery [63]. There is an extensive range of mechanical devices available to reduce the prolapse, but literature on success and complications is inadequate especially if isolated enteroceles are considered. Pessaries are an option, and a trial of pessary fitting can easily be performed in clinics and can be managed by educated nurses or continence advisers. In a comparative study, pessaries alleviated pelvic floor symptoms similarly to prolapse surgery [63]. Dissatisfaction with pessary treatment was associated with the development of occult stress urinary incontinence [65]. The failure rates are high if there is insufficient pelvic floor support present and an additional solid repair is omitted.

Renal dysplasia and renal agenesis are associated with Müllerian anomalies and must not be overlooked [8] antibiotics making me tired cheap noroxin 400 mg with amex. However virus cleaner 400 mg noroxin order visa, it does not provide enough information to allow one to discern between a septate uterus and bicornuate uterus infection 6 weeks after giving birth safe 400 mg noroxin. It has two main drawbacks: first treatment for uti from chemist noroxin 400 mg purchase otc, many patients consider it to be an uncomfortable procedure antibiotic resistance nice generic 400 mg noroxin with amex, and it may be complicated by pelvic inflammatory disease. Also, it is not appropriate for the investigation of the adolescent patient and its main use is in the evaluation of subfertility. Hysteroscopy can be useful in the diagnosis of uterine anomalies and has the benefit of allowing treatment in some cases, particularly in septa and arcuate uterus [13]. As hysteroscopy does not provide any information on the outer surface of the uterus, it may be difficult to distinguish between a septate and bicornuate uterus. Diagnostic laparoscopy should be undertaken only in cases where all other imagining modalities have failed, and the potential for combining this with laparoscopic treatment should also be considered [14]. The incidence of imperforate hymen is estimated to be 1 in 1000 live female births [14]. Hymen malformations are not usually associated with other Müllerian or uterine anomalies. Failure of this septum to perforate in embryo or early childhood may present at adolescence with obstructed menstrual flow. The diagnosis may be made prenatally [15] or rarely in the neonatal period with obstruction of the urinary tract [16]. However, the history is usually of several months of cyclical abdominal pain in an adolescent without menstruation. On inspection of the vulva, it is usually possible to see a bulging vaginal membrane. The treatment for these patients is a simple incision with excision of a quadrate of hymenal tissue to allow drainage of the vagina and uterus. Wide excision of the hymen too close to the vaginal epithelium may result in stenosis at the introitus [17]. There have been case reports of familial cases of imperforate hymen usually between siblings, suggesting a recessive mode of inheritance [18]. There has also been a report of imperforate hymen in two generations of the same family [19], which suggests a possible dominant mode of transmission. Transverse Vaginal Septa this uncommon condition occurs in approximately 1 in 70,000 females [20]. It occurs due to a failure of the Müllerian ducts and urogenital sinus to canalize. These septa are most commonly found at the junction of the middle to upper two-thirds of the vagina. In cases of a complete transverse septum, associated uterine anomalies are common; one series reports the rate to be as high as 95% [21]. Most presentations of this condition are in young girls after the menarche with cyclical pelvic pain as a result of hematocolpos, which may be complicated by hematometra, bilateral hematosalpinges, and possibly endometriosis. It can usually be easily distinguished clinically from an imperforate hymen as there is no 1679 bulging membrane seen at the introitus. It can rarely occur before puberty when the presentation is with pelvic pain; the obstruction in this case is thought to be due to a buildup of mucous secretions from the cervical glands. In one interesting case, expectant management was employed, where the thickness of the septum and volume of the dilated vagina were monitored regularly using ultrasonography. The thickness of the vaginal septum decreased from 26 to 8 mm over a period of 5 years, thus allowing a less complicated surgical procedure in a more mature patient [22]. The thinning of the septum was felt to be due to a pressure effect of the hematocolpos. However, in the majority of cases, the treatment is surgical excision without delay. If the septa are thin and low, it may be possible to remove using a vaginal approach [24]. Care must be taken to ensure the septum is entirely removed as vaginal stenosis may result if the procedure is incomplete. Thick transverse septa or those located higher up in the vagina will require an abdominoperineal approach, which may be open or laparoscopic [25]. In those cases where the distance between the margins is too great, then some form of graft, either with skin or intestine, will be required. Longitudinal Vaginal Septa Longitudinal septa are often asymptomatic and may not present until the patient is sexually active with dyspareunia, or in some cases during labor where there may be a delay in the second stage [26]. They result as a failure of reabsorption of the vaginal septum during embryogenesis. It may be complete, and extend from the cervix to the introitus, or partial, which may be of any length along the course of the vagina. The management for the majority of these is usually surgical resection if symptomatic. Care must be taken to resect the septum right up to the cervix or dyspareunia will continue. This may cause an unusual clinical picture of apparently normal menstruation, from the unaffected side associated with pelvic pain. As menstruation appears initially normal, this results in delayed diagnosis of obstruction that would normally be made much quicker in the absence of any menstrual flow. Also, as this is an uncommon condition presenting in young females, the patient may present to a pediatrician rather than a gynecologist, especially as the patients are having what appears to be normal periods. Over 80% are thought to have an associated uterine malformation, the commonest of which is a complete uterine septum [21]. Surgical treatment of simple vaginal longitudinal septa is generally uncomplicated and is approached vaginally. As with transverse septa and imperforate hymen, postoperative vaginal stenosis should be looked for and treated if necessary. Uterine Anomalies Traditionally, it has been reported that uterine anomalies are present in 0. However, a recent cross-sectional study undertaken in Denmark has demonstrated an anomaly rate of 9. However, there was no association with miscarriage and Müllerian anomalies reported, which is contrary to previous reports in the literature [27]. The most widely accepted classification system for uterine anomalies is from the American Society for Reproductive Medicine [30]. The resulting anomalies can be considered to be due to one of four events [31]: 1. Failure of one or more of the Müllerian ducts to develop: Agenesis, unicornuate uterus without rudimentary horn 2. Failure of the ducts to canalize: Unicornuate uterus with rudimentary horn 1680 3. Failure of or abnormal fusion of the ducts: Uterus didelphys, bicornuate uterus 4. Failure of the reabsorption of the midline uterine septum: Septate uterus, arcuate uterus the most common of these appears to be septate uterus, which accounts for approximately 35% of all uterine anomalies [31]. It is known to result in early pregnancy loss and infertility, and this is how the majority of these patients present. However, septa can also be found by chance in women with an uncomplicated obstetric history and so the decision on treatment can be complex. If treatment is recommended, then the most appropriate treatment for septate and arcuate uterus is resection of the septum, which can be achieved via hysteroscopic metroplasty, thus avoiding the need for a laparotomy and an incision in the uterus. There is some evidence that metroplasty may improve reproductive outcomes in these women [32]. These patients also have recurrent miscarriage, premature delivery, and infertility. There have also been reported neonatal risks, and these include low Apgar scores and small-for-date infants. Pregnancies do occur in these women and they should be carefully monitored throughout. This is complicated further if there are multiple pregnancies, and twin pregnancies in bicornuate uterus have been reported [33,34]. Unicornuate uterus results from the normal differentiation of only one Müllerian duct. One study demonstrated a preterm delivery rate of 25% and early miscarriage rate of 37. Presentation as an adolescent can be delayed as the presence of normal menstruation from the unobstructed side leads to a low index of suspicion. Removal 1681 of the horn is essential to treat pain but also as pregnancy may occur within the horn [37]. There have been reports of removal of pregnant uterine horns, and in this situation the risks are greater as the pregnant uterus is a more vascular structure. Furthermore, it is suggested that the standard treatment of cases such as these should include fetocide and methotrexate; this in addition to gonadotropin-releasing hormone would allow a safer approach to the laparoscopic removal of the uterine horn. The obstetric outcomes in subsequent pregnancies of this group of patients are better than expected. In a large cohort of 120 consecutive females with a diagnosis of unicornuate uterus having a total of 341 pregnancies, the live birth rate was reported as 72. Didelphic uterus is often associated with a hemivagina, or a vaginal septum of varying degree, and possible duplicated kidneys or renal agenesis. Absent Cervix Congenital absence of the cervix is a rare condition and occurs in 1 in 80,000­100,000 births [40]. It is known to be associated with vaginal aplasia, both partial and complete, and renal anomalies. In a recent retrospective review of 18 patients, 39% had associated vaginal aplasia. Presentation is usually with primary amenorrhea and cyclical lower abdominal pain. The differential diagnosis includes high transverse vaginal septum, and in some cases, the actual diagnosis may not be clear until surgery. The management of this condition has changed in recent years with the advances of reproductive technology. Previously, patients with cervical atresia were offered a total hysterectomy as complications of recanalizing the cervix were common and a viable pregnancy was unlikely [26,42]. Now the recommended treatment options consist of either suppression of menses with preservation of the uterus for pregnancy with reproductive assistance or uterovaginal anastomosis, which can now be performed laparoscopically [40]. There are very little data on fertility outcomes following uterovaginal anastomosis; the largest study published stated that the postoperative complication rate was low with only 22% requiring further surgery. Furthermore, they report six spontaneous pregnancies in four of their patients [41]. Despite these encouraging results, it is important to realize that the possibility of serious complications exists and postoperative sepsis after uterovaginal anastomosis has resulted in septic shock and death [43]. Reproductive technology has advanced to allow these patients an opportunity to become pregnant and in vitro fertilization techniques have assisted these patients to become pregnant. There have been case reports of implanting embryos transmyometrially, which have resulted in a viable pregnancy [44,45]. In the latter case report, the patient underwent uterovaginal canalization using amniotic membrane at the time of cesarean section [45]. One of the difficulties of these techniques is the management of miscarriage should it occur. Cervical dilation and curettage is often not an option as there may be no 1682 obvious cervix, or a small scarred stenosis. Therefore, most cases would require a laparoscopic or open removal of the remnants of pregnancy. This allows us to distinguish between them based upon the underlying cause rather than the system affected. Congenital Absence of the Vagina Agenesis of the vagina occurs in approximately 1 in 5,000­30,000 live female births [46,47]. In the majority of suffers, there is no discernable vagina present, while approximately 25% will have a short blind-ending pouch. Anomalies of the urinary tract are present in an estimated 34% of patients, and spinal anomalies are found in 12% [48]. The preferred method for this is nonsurgical with the use of pressure dilation therapy [52]. In most patients while there is no vagina, there is often a vaginal dimple that acts as a guide for patients to apply pressure on the site. Success of this treatment is high [49] but is limited to motivated patients, and it is recommended that they are seen regularly during this treatment and offered psychological support to improve outcomes. For those in whom dilation has not worked or is not possible, then surgical construction is necessary. The timing of this procedure should be carefully considered, as many of those who have surgery will need to use some form of pressure dilation subsequently to maintain the vagina. Numerous forms of vaginoplasty have been employed in the treatment of these patients. The use of bowel segments for vaginoplasty has been reported in the literature as early as 1907 [53]; segments of the rectum, ileum, and sigmoid colon may be employed. Stenosis (apart from at the introitus) is rare and the vagina remains moist and of appropriate caliber. However, a vagina constructed from the intestine will be relatively insensitive and may have excess mucus production requiring the patient to wear pads permanently. There have been reports of diversion colitis with colovaginoplasty and this can be difficult to treat [54].

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In those patients who retain the device antibiotics cipro 400 mg noroxin order mastercard, continence is significantly improved in over 75% [56] antibiotics beer buy noroxin canada. Incontinence scores and quality-of-life scores can be vastly improved with the device [56­62] antibiotic and pregnancy noroxin 400 mg buy with amex. Device failure and infection are the most common complications antibiotic pronunciation discount 400 mg noroxin mastercard, leading to device explantation in up to 50% of patients [64 how long do you take antibiotics for sinus infection noroxin 400 mg amex,65]. Meticulous surgical technique by an experienced surgeon is essential to minimize the potential complications, though they unfortunately do still occur with the artificial bowel sphincter. The patient is placed in the modified lithotomy position under general anesthesia. Meticulous sterile preparation and technique are employed throughout the procedure. Dissection down to the rectum is performed and then extended laterally and posteriorly. Blunt dissection is required to encircle the rectum, and this is then measured with the cuff sizer to choose the appropriate device size. Once the artificial sphincter, or cuff, is chosen, it is placed around the anal canal and closed. The clear tubing from the cuff is tunneled to the space of Retzius and a trial filling is undertaken. A dilator is then used to create a tunnel and a pocket in the labus majorum or the scrotum. Care must be taken to ensure that all components of the device are as deep as possible, so as to avoid the risks of infection and device erosion. Once the pump is activated in the clinic after 6 weeks, the patient will begin using the artificial bowel sphincter. At baseline, the cuff is filled with liquid, thus providing the bulk of an anal sphincter and therefore continence. When the patient pumps the device, the fluid leaves the cuff and enters the reservoir. It then slowly refills over a period of about 2­3 minutes, during which time the patient is able to have a bowel movement with good control. The manufacturer of the artificial bowel sphincter (American Medical Systems, Minnetonka, Minnesota) has recently discontinued distribution and support of this device; thus, it is no longer available for implantation. Dynamic Graciloplasty Muscle transposition was developed to replace the anal sphincter complex with autologous muscle bulk. Gluteoplasty with bilateral tongues of the gluteus maximus has been described but never gained popularity [66]. The more popular muscle is the gracilis muscle from the leg, which is considered the gold standard for muscle transfer. The gracilis is a useful muscle due to its long length, substantial bulk, and single proximal neurovascular pedicle in most patients. In attempts to reproduce this success in larger trials, nerve stimulation, or dynamic graciloplasty, was introduced. Long-term success of dynamic graciloplasty is reported to be between 60% and 75% [68­74]. A multicenter North American trial of dynamic graciloplasty found that function continued to improve and be sustained up to 24 months, and that continence was slower to improve in patients who originally had a stoma at the time of the graciloplasty procedure [74]. Stimulation of the gracilis occurs either with direct stimulation by an implanted lead or temporary stimulation with an external stimulator to retrain the gracilis. Dynamic graciloplasty is not without problems, including infection, pain, and erosion of the stimulator lead [73,75]. Currently, the procedure 1435 is not approved for use in North America but continues to be offered to specific patients in Europe and elsewhere. Graciloplasty is performed with the patient under general anesthesia, but without muscle paralysis. The location and course of the gracilis muscle is palpated and marked along the medial aspect of the thigh. Two or three longitudinal incisions are made proximally and distally over the muscle. The insertion tendon is divided near the knee and the muscle is then divided from its deep perforating blood supply. At the medial aspect of the gracilis, meticulous care must be taken to preserve the neurovascular bundle. Confirmation of the identification of the nerve is done through direct nerve stimulation. Left and right circumanal incisions are made as deeply as possible and the gracilis is delivered into the perineal incision and circumferentially wrapped around the distal rectum to re-create the anal sphincter complex. It is sutured in place to either the ipsilateral or contralateral ischial tuberosity. Postoperatively, the patient is placed on bed rest in an adduction splint for 72 hours to prevent early failure of the muscle wrap. Magnetic Anal Sphincter A newer device has been developed to simplify the concept of sphincter replacement. The magnetic anal sphincter provides anal pressure and baseline tone at rest, which is overcome during pushing to open the anal canal and allow for defecation. It is currently undergoing clinical trials and is not approved for use in North America. Another study comparing the magnetic anal sphincter to the artificial bowel sphincter found equivalent improvements in incontinence and similar complication rates, but shorter hospital stay and operative time in the magnetic anal sphincter group [77]. While long-term results are not yet available, it appears that about two-thirds of patients are satisfied with the results of the procedure at about 2 years [78]. Complications of the procedure include bleeding, infection, pain, obstructed defecation, device failure, and device erosion [76]. The need for device explantation appears to be lower than that of the artificial bowel sphincter, but the data are sparse in these small trials. The magnetic anal sphincter is implanted under general anesthesia as an inpatient surgery. Much like graciloplasty and artificial bowel sphincter procedures, a circumferential tunnel is created around the anal canal with sharp and blunt dissection. The magnetic sphincter is then fit to size by removing or adding magnetic beads to the chain. The chain of magnetic beads is then wrapped around the rectum and secured in place. The device must be snug enough to provide resting tone and continence, but loose enough that the magnets will be overcome by Valsalva maneuver during defecation and not cause outlet obstruction­type constipation. The incision is then closed and the patient is treated with antibiotics in the postoperative period to reduce the risk of device infection. This is a promising procedure that may provide a less complicated alternative to the artificial bowel sphincter and dynamic graciloplasty in the near future. Not only is there direct stimulation of S3 on the anal sphincters, but it also improves the sensation of rectal filling, alters colonic transit, and increases central nervous activity at the level of the cerebral cortex [83­86]. Infection, pain, and device migration are the most common complications of the procedure, which occur in about 10% of patients [91,94,95]. The device consists of a tined quadripolar electrode lead and implantable pulse generator. During the first phase of the procedure, that patient is placed in the prone position in the operating room under light sedation. Using mostly local anesthesia for pain control, the tined lead is introduced into the medial aspect of the S3 foramen via a posterior approach. Fluoroscopic guidance is used to plan the insertion point and assess the depth of the lead. By stimulating the guide wire and then the lead, confirmation of good placement is achieved in three ways: by looking for plantar flexion of the great toe, visualizing anal bellows (inward retraction of the anus), and asking the patient to report stimulation in the perineal area. Once a good response is confirmed, the lead is deployed in position and attached to a temporary external stimulator. If the patient experiences a 50% reduction in incontinent episodes, the second stage of the procedure is completed. Alternatively, a temporary lead may be placed in the office setting with local anesthesia using bony landmarks to guide placement. If a good response is attained, this temporary lead is again attached to an external stimulator for 3­5 days. During the second stage, the implantable pulse generator, similar to a cardiac pacemaker, is inserted deep in the gluteal fat, just above the gluteal fascia. If an office-based test phase with a temporary lead had been performed, the permanent tined quadripolar electrode lead is also placed during the second stage of the procedure. The patient controls the intensity of the stimulation and can also adjust which of the four electrodes is being stimulated using the control device. Patients undergo percutaneous or transcutaneous tibial nerve stimulation in an outpatient setting for 30 minutes at a time for about 12 weeks. A systematic review recently found that both percutaneous and transcutaneous stimulation are effective modalities [98]. At least, a 50% reduction in fecal incontinent episodes is seen in over two-thirds of patients [98­101]. Long-term follow-up beyond 2 years is not yet known, though it is clear that patients need to undergo monthly treatment to maintain the durability of the response, similar to biofeedback. A surface electrode or needle electrode is placed just posterior and caudal to the medial malleolus of one elevated leg with the patient awake in the lying or sitting position. If a needle electrode is used, the goal is to place it near, but not directly into, the posterior tibial nerve. Pulse stimulation is performed and correct placement of the electrode is confirmed by visualizing flexion or fanning of the toes and plantar flexion of the foot. Sensory stimulation may also be reported by the patient on the plantar aspect of the foot. The patient typically undergoes 1 or more sessions per week over a course of 12 weeks. This most commonly occurs in institutionalized patients or those with neurogenic bowels due to spina bifida. It allows for the patient to effectively flush out the colon daily in a controlled setting to avoid the problem of overflow incontinence. It is also important to note that many patients do not continue to perform antegrade enemas in the long term [103]. Problems with the procedure include infection and leakage or stenosis of the access site that may require a revision. Thus, it is a procedure worth considering in a very select adult patient population. The distal ileum, appendix, cecum, and even left colon have been used as access points. The appendix is the most commonly used, as it can be inverted at the level of the skin to act as a channel for the irrigation catheter. The procedure should be laparoscopically performed, if feasible, to enhance recovery. After the access point is left fixed to the skin, a catheter is left in place for a few weeks to allow for the site to mature. The patient or caregiver is educated on how to perform intermittent catheterization of the access point. Then, large volumes of water or a bowel cleansing solution are used to flush the colon every 1 to few days. Both water and cleansing solutions are effective and the choice largely depends on patient preference and effectiveness. While this may seem to be a burdensome procedure, it can afford selected children and adults better hygiene and social independence throughout the day. Patients are often worried about the social stigma and embarrassment of a colostomy or ileostomy and so are often hesitant to proceed, unless the symptoms are severe. It should be considered, though, to be a very well-tolerated option for those with severe incontinence. Unless the patient has impaired colonic transit, a colostomy is preferred over ileostomy due to thicker and more formed stools from a colostomy, which are easier to manage. In the current era of minimally invasive surgery, a diverting colostomy can be laparoscopically created to minimize the morbidities of surgery, including bleeding, infection, incisional hernia, and cardiac or respiratory complications. Obstetric trauma, pelvic floor injury and fecal incontinence: A populationbased case-control study. Weight loss improves fecal incontinence severity in overweight and obese women with urinary incontinence. Current status: New technologies for the treatment of patients with fecal incontinence. Long-term outcome and objective changes of anorectal function after biofeedback therapy for faecal incontinence. Biofeedback for fecal incontinence: Short-term outcomes of 513 consecutive patients and predictors of successful treatment. Biofeedback training is useful in fecal incontinence but disappointing in constipation. Randomized, controlled trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance along in the treatment of mild to moderate fecal incontinence. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercised for fecal incontinence.

Xenoderm was a dried preparation requiring preliminary soaking before implantation infection 2 months after surgery discount 400 mg noroxin fast delivery, while Pelvicol is a prewetted dermal graft that handles much like a piece of autologous fascia antibiotics via iv noroxin 400 mg amex. Case series presenting early outcomes from Pelvicol implantation [133] promised encouraging efficacy infection synonym noroxin 400 mg purchase, but longer-term studies have shown unacceptable failure rates antibiotics by class noroxin 400 mg purchase fast delivery. The material was awkward to handle and was withdrawn from the market by the manufacturers in the mid-1990s antibiotics give uti buy noroxin 400 mg otc. Small intestinal submucosa has also been used for urethral support as well as many other uses. There have been conflicting reports on the extent of tissue reaction related to the use of this tissue [140,141]. Synthetics As aforementioned, the long-term durability of these procedures with graft materials has been questioned, with reports of graft failure and declining success rates over time [5]. As such, the midurethral synthetic sling was developed, replacing the pubovaginal sling as the gold standard for stress incontinence, and thus, polypropylene mesh is worth mentioning here as a graft material though it is discussed at length in another chapter [142]. Nonetheless, patients are not necessarily aware of these differences and should be counseled appropriately prior to any surgical intervention, especially when voicing concerns about mesh placement [144]. As such, patients should be informed that synthetic slings are considered a first-line treatment option for stress incontinence. Attempts to improve this coaptation effect through minimally invasive injection techniques have challenged clinicians for over 50 years. The mechanics of urethral bulking seem to be that by increasing the passive resistance of the urethra, leakage is diminished. The ideal injection material should be nonimmunogenic, thus causing no localized inflammatory reaction; stable chemically; nondegradable so that its bulking effect remains; and easy to inject to minimize the difficulties of surgery. Since most of these agents consist of particles suspended in a carrier gel or fluid, it is also important that the particles are large enough not to be absorbed and risk migration, and for as little carrier gel as possible to be absorbed, which results in reduction in efficacy. The first injection techniques to be tried and reported were by Murless in 1938 [146]. He used sclerosing agent, sodium morrhuate, in 20 women and achieved continence in 17 of them, presumably through the effect of scarring and contracture of the vaginal wall. Quakels in 1955 used paraffin to achieve the same effect, but reports of pulmonary embolism stopped the technique [147]. The speed of this procedure and its apparent efficacy, even if this was lower than conventional surgery, appeared to offer a truly minimally invasive alternative to surgery for women who wanted to avoid the risk of morbidity. However, reports of serious complications began to emerge including periurethral abscess [152,153] pulmonary granulomata [154,155], and obstructive uropathy [156], and long-term outcomes were observed to deteriorate from 80% initial response to 27% at 3 years [157] and to 33% at 5 years [158]. Gonzales de Garibay, in 1989, reported an alternative bulking agent that utilized autologous fat cells obtained by microliposuction and reinjected into the periurethral tissues [159]. This had the major advantage of being autologous tissue with no immunogenicity problems, cheapness, and ease of use. However, the initial results were disappointing with only 23% of women improved at 12 months [160] and none in another study [161] though Palma achieved 64% cure at 12 months by means of repeated injections [162]. Of the 68 women enrolled, 35 received fat and 33 received saline injections of whom 22% and 20%, respectively, were improved at three months. Much further research and clinical development has continued into the modern era using a variety of injectable materials. In brief, recently developed injectables such as silicon particles and calcium hydroxylapatite can result in an improvement in incontinence, but patients may not necessarily achieve dryness. According to the 2012 Cochrane Review on injection therapy for urinary incontinence, there is insufficient evidence in the use of bulking agents to guide clinical practice, and this is discussed in detail in another chapter [164]. Nevertheless, understanding these procedures is paramount as our current surgical treatment options are based on these fundamental surgical principles. The continued use of what some would regard as archaic may be defensible in experienced hands, where the outcomes are well monitored and known to surgeon and patient alike. Thus, scrutiny of surgical technique and materials is becoming commonplace, ultimately providing better patient care, which is the ultimate goal. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5year follow up. A randomised controlled trial comparing two autologous fascial sling techniques for the treatment of stress urinary incontinence in women: Short, medium and long-term follow-up. Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele. Primary stress urinary incontinence and pelvic relaxation: Prospective randomized comparison of three different operations. Three surgical procedures for genuine stress incontinence: Five-year follow-up of a prospective randomized study. A randomized trial of burch retropubic urethropexy and anterior colporrhaphy for stress urinary incontinence. Four-corner bladder and urethral retropubic suspension versus anterior colporrhaphy in the correction of stress urinary incontinence with urethrocystocele 3­4. A prospective, randomized and controlled trial for the treatment of anterior vaginal wall prolapse: Medium-term follow-up. Evaluation of long-term results of surgical correction of stress urinary incontinence. Comparison of the anterior colporrhaphy procedure and the Marshall­ Marchetti­Krantz operation in the treatment of stress urinary incontinence among women. Ten-year results of Marshall­Marchetti­Krantz and anterior colporraphy procedures. Surgical treatment of stress urinary incontinence: A comparison of the Kelly plication, Marshall­Marchetti­Krantz, and Pereyra procedures. Retropubic cystourethropexy: A review of two operative procedures with long-term follow-up. Paravaginal repair of lateral vaginal wall defects by fixation to the ischial periosteum and obturator membrane. The Stamey endoscopic bladder neck suspension: A clinical and urodynamic investigation, including actuarial follow-up over four years. Raz double-prong ligature carrier for transvaginal bladder and bladder neck needle suspension. Burch colposuspension versus Stamey endoscopic bladder neck suspension: A urodynamic appraisal. Comparative analysis of bladder neck suspension using Raz, Burch and transvaginal Burch procedures. Comparison of three different surgical procedures for genuine stress 1108 incontinence: Prospective randomized study. Stress urinary incontinence: A comparative study of surgical treatment by the Marshall­Marchetti­Krantz technique with endoscopic suspension of the bladder neck. A clinical and urodynamic study comparison the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence. A randomized controlled trial comparing anatomical and functional outcome between vaginal colposuspension and transvaginal mesh. A comparison of complications with special emphasis on detrusor instability and voiding dysfunction. A comparison of endoscopic suspension of the vesical neck with suprapubic vesicourethropexy for treatment of stress urinary incontinence. Endoscopic bladder neck suspension (Stamey­Pereyra) in female urinary stress incontinence. Long-term results of the Stamey bladder neck suspension: Direct comparison with the Marshall­Marchetti­Krantz procedure. Long-term results of the stamey bladder-neck suspension procedure and of the burch colposuspension. A questionnaire-based outcome analysis of the Stamey bladder neck suspension procedure for the treatment of urinary stress incontinence: the Hannover experience. Success rate of modified Pereyra bladder neck suspension determined by outcomes analysis. Symptom analysis of patients undergoing modified Pereyra bladder neck suspension for stress urinary incontinence. Modified Pereyra bladder neck suspension: 10-year mean followup using outcomes analysis in 125 patients. Modified Pereyra bladder neck suspension in patients with intrinsic sphincter deficiency and bladder neck hypermobility: Patient satisfaction with a mean follow-up of 4 years. Role of the four-corner bladder neck suspension to correct stress incontinence with a mild to moderate cystocele. Placard-shaped in situ vaginal wall sling for the treatment of stress urinary incontinence. Incisionless per vaginal bone anchor cystourethropexy for the treatment of female stress incontinence: Experience with the first 50 patients. Assessment of a new bone anchor system for the treatment of female genuine stress incontinence. Incidence of pubic osteomyelitis after bladder neck suspension using bone anchors. Processed porcine small intestine submucosa as a graft material for pubovaginal slings: Durability and results. Treatment of stress urinary incontinence with percutaneous colposuspension: Unsatisfactory technique. Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction: Efficacy and outcome analysis. Uber die Verwendung der musuli pyramidales bei der operativen behandlung der incontinentia urinae. Comparison of fascial and vaginal wall slings in the management of intrinsic sphincter deficiency. A randomized controlled trial of pubovaginal sling versus vaginal wall sling for stress urinary incontinence. Pubovaginal sling surgery for simple stress urinary incontinence: Analysis by an outcome score. Long term follow up of the cruciate fascial sling for women with genuine stress incontinence. Expanded indications for the pubovaginal sling: Treatment of type 2 or 3 stress incontinence. Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency. Pubovaginal sling using allograft fascia lata versus autograft fascia for all types of stress urinary incontinence: 2-year minimum followup. Pubofascial versus vaginal sling operation for the treatment of stress urinary incontinence: A prospective study. Cadaveric fascia lata versus intravaginal slingplasty for the pubovaginal sling: Surgical outcome, overall success and patient satisfaction rates. Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures. Outcome in 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank. High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence. Comparison of solvent-dehydrated allograft dermis and autograft rectus fascia for pubovaginal sling: Questionnaire-based analysis. Cadaveric fascia lata sling for stress urinary incontinence: A prospective quality-of-life analysis. Cadaveric fascia lata pubovaginal slings: Early results on safety, efficacy and patient satisfaction. Pubovaginal sling using Duraderm graft: Intermediate follow-up and patient satisfaction. Cadaveric versus autologous fascia lata for the pubovaginal sling: Surgical outcome and patient satisfaction. Vaginal paravaginal repair with porcine dermal reinforcement: Correction of advanced anterior vaginal prolapse. Solvent-dehydrated cadaveric dermis: A new allograft for pubovaginal sling surgery. Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence. Comparative analysis of urinary incontinence severity after autologous fascia pubovaginal sling, pubovaginal sling and tension-free vaginal tape. Porcine small intestinal submucosa as a percutaneous mid-urethral sling: 2year results. Small intestinal submucosa for pubourethral sling suspension for the treatment of stress incontinence: First histopathological results in humans. Intense inflammatory reaction with porcine small intestine submucosa pubovaginal sling or tape for stress urinary incontinence. Minimally invasive synthetic sling suburethral sling operations for stress urinary incontinence in women. Deux incontinence apres adenonectomie queries par injection de paraffine daris de perinee. Transurethral polytetrafluoroethylene injection in female patients with urinary continence. Disappointing effect of endoscopic teflon injection for female stress incontinence. Pulmonary teflon granulomas following periurethral teflon injection for urinary incontinence. Long-term follow-up of women treated with periurethral teflon injections for stress incontinence.

They reported trends in utilization and outcomes of both robot-assisted sacrocolpopexy and "open" vaginal vault surgery bacteria jokes generic noroxin 400 mg online. An increase in the proportion of robotic procedures was seen over the time period antibiotic garlic order discount noroxin, from 14 good antibiotics for sinus infection noroxin 400 mg purchase with visa. Blood transfusion and prolonged hospital stay were less likely following robotic surgery yeast infection 8 weeks pregnant noroxin 400 mg purchase, and although intraoperative complications were higher antibiotics with anaerobic coverage generic 400 mg noroxin mastercard, there was no difference in postoperative complications. Hospital charges were significantly lower in the open surgery population compared with robotic surgery patients. Robotic versus Laparoscopic Sacrocolpopexy Two randomized trials, and a retrospective cohort study comparing clinical outcomes and costs of robotic and laparoscopic sacrocolpopexy, have found robotic surgery costs to be higher than those of laparoscopic surgery [18,19,26]. Operating time was longer by 67 minutes, 14 minutes of which was robot docking time, in the robotic group. The differences in the two procedures, such as intracorporeal knot tying in the robotic group and extracorporeal in the laparoscopic group, may also have contributed to longer robotic operating time. It was postulated that differences in pain might be due to the greater number and size of ports in the robotic arm. This is a conservative estimate as robot acquisition and maintenance costs were not included in the analysis. The difference in costs was accounted for by the operating room costs since costs associated with hospital stay and postoperative care were similar. The other randomized trial of robotic and laparoscopic sacrocolpopexy reported surgical costs and costs associated with rehospitalization up to 6 weeks, as well as outcomes at 6 months [19]. Costs were derived from applying a cost-to-charge ratio to the hospital charges rather than from accounting for individual costs of items used. Operating time was longer in the robotic group and short-term pain was greater in this group. It was felt that the increase in pain might be related to the operating time and the increased tension on the robotic ports due to a lack of tactile feedback from robotic surgery; i. Over 6 weeks, costs were higher for robotic surgery 1553 ($19,616 versus $11,573) but when purchase and maintenance costs were excluded, the cost difference decreased to only $1,000. They concluded that the higher costs were as a result of the robot purchase and maintenance, rather than surgical costs. Both of these studies stipulated that surgeons should have performed at least 10 of procedures of each type prior to starting the study. It is possible that the surgeons, who were experienced laparoscopists, were still at the start of the learning curve of robotic surgery after 10 cases. In the retrospective cohort study of 104 subjects, Tan-Kim also found that costs were higher for robotic surgery. Differences in surgical technique between the procedures may have contributed to this. Titanium tacks were used to fix the mesh to the sacrum in the laparoscopic group whereas suturing with intracorporeal knot tying was the method in the robotic group. Robot docking time accounted for only 9 of the 72 minutes difference in operating times. They also acknowledge that the study covered a period when some of their surgeons were at the start of their learning curve for the procedures. Cost Comparisons of Open, Laparoscopic, and Robotic Sacrocolpopexy A cost-minimization analysis by Judd [27] concluded that robotic was more expensive than laparoscopic or open sacrocolpopexy under baseline assumptions. They used two models; one based on current hospital ownership of a robotic system and one including the purchase and maintenance costs. Sensitivity analyses were performed to assess the effect of varying the parameters. They found robotic sacrocolpopexy to be the most expensive, with an incremental cost of $1155 over laparoscopic and $2716 over open sacrocolpopexy. Robotic and laparoscopic surgery costs only became equivalent when robotic operating time is reduced to 149 minutes, robotic disposable costs reduced to $2132, or laparoscopic disposable costs increased to $3413. The additional costs associated with the robot purchase model were between $581 and $1724 per procedure, depending on robotic throughput. The cost differences reflect higher disposable equipment costs and longer operating time. Despite these findings, the authors suggest that continued robotic innovation might lead to future cost savings in terms of reduced operating time and cheaper equipment. Operation times in this study were significantly greater than other referenced studies (418 minutes for open, 510 for laparoscopic, and 358 for robotic procedures). The estimated direct costs were higher for robotic surgery than open but not significantly different for robotic and laparoscopic approaches. It is not clear whether costs associated with robot purchase and maintenance are included in this analysis. Learning Curve of Laparoscopic and Robotic Sacrocolpopexy the learning process of laparoscopic sacrocolpopexy presents a challenge to most urogynecologists. Many of them have little experience of advanced laparoscopic surgery and are traditionally trained as predominantly vaginal surgeons. To become proficient in a new surgical technique, surgeons need a sufficient individual caseload. Even though vaginal prolapse is a common indication for surgery, vault prolapse is relatively uncommon. In order to assess the learning process, it is necessary to define an endpoint at which a surgeon is judged to be proficient. Assessment of the learning curve should include measures of quality and efficiency. Quality of surgery can be assessed by functional outcomes or by complication rates. Efficiency is usually assessed by measuring duration of surgery but may also include conversion to open surgery. A number of studies have attempted to quantify the learning curve of laparoscopic sacrocolpopexy. They focus on the number of cases required to reduce the operating time, largely due to low rates of reported complications associated with the procedure in the studies [28­30]. Operating time declined rapidly during the first 30 cases in the study reported by 1554 Claerhout et al. Dissection of the vault was the most time-consuming step; times comparable with the teacher (the control) were achieved after 31 cases. Duration of suturing fell within the range of the teacher after only 10 cases, but it should be noted that the participants had attended a 15 hour laparoscopic skills lab prior to commencement of the study. There was no learning curve associated with dissection and fixation to the sacral promontory. Two studies have found operative times to drop significantly after just 10 cases [32,33]. The learning curve of robotic hysterectomy has found to be significantly longer than these small series suggest. The extent to which this study can be extrapolated to robotic sacrocolpopexy is debatable and further studies of the learning process are required for this procedure. They demonstrated that the robot allowed suturing and dexterity skills to be performed more quickly than with laparoscopic assistance after only five trials. The study is limited by the small number of participants, the lack of standardized dexterity tasks, and the number of times each participant performed the task. It would have been useful to increase the number of trials to determine how many are required for participants to reach their plateau. From the available evidence, it would appear that proficiency in laparoscopic sacrocolpopexy, based on duration of surgery, is achieved after 30­90 cases. There is some evidence to suggest that some of the necessary skills for minimally invasive sacrocolpopexy are acquired more quickly using robot assistance. The high cost of robotic surgery needs to be evaluated carefully in terms of evidence-based outcomes. Similar short-term outcomes have been reported for open, laparoscopic, and robotic sacrocolpopexy. Formal cost-effectiveness analysis has not been undertaken for different surgical approaches to sacrocolpopexy; the majority of studies use cost-minimization analysis to estimate costs from the hospital perspective. Longer-term studies, including data on quality of life, long-term outcomes, complications, and the need for further surgery, would allow the cost to society of such surgery to be evaluated. Interpretation of the literature with regard to cost is problematic, and the results of studies comparing robotic surgery costs to other routes are conflicting. Conclusions vary considerably depending on the model used, the assumptions made, and the method of analysis. Large variation in operating time is reported and there is a lack of clarity in many studies as to how operating time is defined. Other factors that need to be taken into consideration when assessing operating time in studies include a. Equipment costs account for a large part of the difference between open versus laparoscopic or robotic costs. There are differences in the extent to which all possible items are accounted for in different studies as well as the time period over which the study is undertaken. Some studies 1555 only include inpatient costs, whereas others itemize costs up to 6 weeks postoperatively. Surgeons outside the United States may struggle to interpret the cost data from existing literature and the extent to which it can be extrapolated to their own health-care systems. There have been no studies of costs associated with robotic sacrocolpopexy in settings outside of the United States. Robotic technology will continue to develop and is likely to become cheaper as new manufacturers enter the market. There is currently a lack of competition to the da Vinci system, which may, in part, stem from patented technologies as well as acquisition of a competitor by Intuitive Surgical in 2003. Whenever there is minimal or no competition in a market, companies are able to command high premiums for their product and operating margins can be higher compared with other companies within that industry [36]. Until competitors enter the market, the only other option to enable more centers to utilize this technology is the emerging availability of cheaper, preowned systems. Despite the heterogeneous nature of the cost comparison studies, they appear to demonstrate that robotic sacrocolpopexy is associated with greater direct costs than the laparoscopic approach (Table 105. While improvements in the technique and technology, together with future market competition, may drive down costs, robotic sacrocolpopexy does not yet appear to be cost effective compared with the open and laparoscopic approaches. A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy. A cost-utility analysis of tension-free vaginal tape versus colposuspension for primary urodynamic 1556 stress incontinence. Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: A randomized controlled trial. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Robotic-assisted laparoscopic surgery for hysterectomy and pelvic organ prolapse repair. Utilization and perioperative outcomes of robotic vaginal vault suspension compared to abdominal or vaginal approaches for pelvic organ prolapse. Robotic-assisted and laparoscopic sacrocolpopexy: Comparing operative times, costs and outcomes. Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. Analysis of the learning process for laparoscopic sacrocolpopexy: Identification of challenging steps. Long-term outcomes after totally robotic sacrocolpopexy for treatment of pelvic organ prolapse. They can occur in a number of anatomical locations along the urinary tract and the female reproductive system (Table 106. Over 90% of these are obstetrical in nature, caused by obstructed labor and poor access to medical care [2]. In contrast, the majority (90%) of urogenital fistulas in the developed world are iatrogenic, occurring after pelvic surgery [3­5]. There are an estimated 500,000 women with untreated urogenital fistulas worldwide [6]. Many women in developing countries never present for treatment due to poor access to care and lack of financial resources. In one study, women who sought treatment presented an average of 5 years after the development of symptoms. The incidence of urogenital fistula in the developing world has been estimated to be 30,000­130,000 per year [1]. However, these data are limited by the inability to differentiate between primary repairs, reoperations, and erroneous medical coding. Furthermore, this figure does not account for fistulas that were managed on an outpatient basis or managed conservatively without surgical intervention. The medicolegal implications and financial impact on the healthcare system are also important considerations [10]. In order to minimize the negative impact of urogenital fistula, accurate and timely diagnosis is critical. Effective management requires accurate diagnosis and avoidance of unnecessary tests and therapies.

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• Enalapril-hydrochlorothiazide
• Diclofenac sodium
• Glyburide(glibenclamide)-metformin

References

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