You are discussing surgical options with the family of an elderly patient with symptomatic pelvic organ prolapse. Le Fort colpocleisis may be more appropriate than vaginal hysterectomy and A&P repair for patients in which of the following circumstances?
Partial colpocleisis by the Le Fort procedure is reasonable for elderly patients who are not good candidates for surgery as treatment for uterine prolapse. The technique is appropriate for women who have a uterus in situ, and involves partial denudation of opposing surfaces of the vaginal mucosa followed by surgical apposition, thereby resulting in partial obliteration of the vagina. Small strips of vaginal epithelium are left laterally, to allow an outlet for drainage or bleeding. Patients who are candidates for this procedure must have no evidence of cervical dysplasia or endometrial hyperplasia, and must have an atrophic endometrium. This type of obliterative procedure is ideal for women who cannot tolerate a more extensive surgery and who no longer plan to have vaginal intercourse. A similar obliterative procedure may be performed in women who have already undergone hysterectomy, as treatment for vaginal prolapse. Urinary incontinence can be a side effect of these procedures, so many surgeons perform a concomitant incontinence procedure at the same time. An A&P repair essentially involves excision of redundant mucosa along the A&P walls of the vagina, at the same time strengthening the vaginal walls by suturing the lateral paravaginal fascia together in the midline.
A 65-year-old woman presents to your office for evaluation of pelvic organ prolapse (POP). Her past medical history is significant for chronic hypertension, which is well controlled with a calcium channel blocker. She also has chronic constipation which requires use of a laxative to have a bowel movement. She has smoked for over 30 years, and has a chronic cough. She entered menopause at the age of 52 years, but has never taken hormone replacement therapy. Her obstetric history includes three term vaginal deliveries. Her last baby weighed 9 lb, and required a forceps delivery. The delivery was complicated by a large tear that involved the vagina and rectum.
Which of the following factors is least important in the subsequent development of POP in this patient?
POP involves herniation of the pelvic organs to or beyond the vaginal walls. Chronic cough, constipation, obstetric trauma, and menopause are all risk factors for this condition. Undoubtedly, the most important factor is the actual quality of the tissue itself. There is a much lower incidence of POP in black women compared to white women. Any factors that increase intra-abdominal pressure can aggravate or further deteriorate the prolapse. Vaginal delivery is a risk factor for POP, and operative vaginal delivery may further increase the risk. High birth weight also contributes to development of POP. Chronic hypertension is not a risk factor for POP.
A 43-year-old G2P2 woman is being evaluated for hysterectomy for abnormal uterine bleeding that has not responded to conservative management. She mentions during her evaluation that she has a 2-year history of leaking urine when she coughs, sneezes, or laughs. She does not appreciate a sense of urgency. She has to wear a pad when she leaves the house because of the leaking. She has tried Kegel exercises, but has not had any improvement. A urine culture and post void residual (PVR) are normal. A cough stress test in the office demonstrates leaking urine.
What is the most appropriate surgical procedure to manage this problem?
A mid-urethral sling is the procedure of choice in women undergoing primary surgery for uncomplicated SUI. For many years, the Burch retropubic colposuspension was considered the gold standard; however, mid-urethral slings have been shown to have comparable success rates, and are less invasive with a shorter operative time and faster recovery. The MMK is a type of bladder neck suspension, and the Stamey is a needle urethropexy; both procedures are no longer used. Anterior repair with Kelly plication is not an effective surgery for treatment of SUI.
A 30-year-old G3P3 is being evaluated for urinary urgency, frequency, and dysuria. She also reports post-void dribbling of urine and insertional dyspareunia. Her history is significant for recurrent urinary tract infections (UTIs) as a teenager, but no other medical problems. She has had three term spontaneous vaginal deliveries, and her last baby weighed over 9 lb. She recalls having a vaginal laceration requiring multiple sutures after delivery of that child. On pelvic examination, she has a 1-cm tender suburethral mass. Palpation of the mass results in expression of a small amount of blood-tinged purulent discharge.
Which of the following is the most likely cause of this patient’s problem?
Urethral diverticula occur in 3% to 4% of all women. Classic symptoms include urinary frequency, urgency, dysuria, hematuria, and dyspareunia. Patients often report a history of frequent UTIs, dribbling, or incontinence. A urethral diverticulum is often palpable as a tender mass on the anterior vaginal wall under the urethra. Although urethral polyps, eversion, fistula, and stricture may present with similar symptoms, there is no suburethral mass present on examination.
You evaluate a 39-year-old G2P2 on postoperative day 2 following a difficult abdominal hysterectomy for endometriosis. Her surgery was complicated by hemorrhage from the left uterine artery pedicle that required multiple sutures to control bleeding. Her estimated blood loss was 500 mL. Her only other medical problem is obesity, and her prior surgeries are two cesarean deliveries. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are height 5 ft 2 in, weight 250 lb, temperature 38.2°C (100.8°F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 g/dl to 9.8 g/dl, her white blood cell count is 9.5 L, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL.
What is next best step in the management of this patient?
The patient most likely has a ureteral injury near the location of the left uterine artery. A noninvasive renal ultrasound is fast, inexpensive, and accurate way to make the diagnosis by evaluating for hydronephrosis and/or a retroperitoneal fluid collection. Cystoscopy with retrograde intravenous pyelogram has largely been replaced by computed tomography (CT). A CT scan with contrast gives excellent information about the integrity and function of the renal collecting system; however, when the serum creatinine is elevated, intravenous contrast can cause significant renal damage and is contraindicated in those circumstances. A chest x-ray would not be helpful in making the diagnosis. Intravenous antibiotics are not indicated at this time since there is not clear evidence of an infection (normal white blood cell count). The patient has a normal drop in hemoglobin for the surgical blood loss, and does not have signs of hemodynamic instability to warrant a blood transfusion at this time.
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