Citations

A wide variety of fistulae occur in the female pelvis, most of which cause significant morbidity. Diagnosis, characterization, and treatment planning may be difficult using traditional imaging modalities such as fluoroscopy and computed tomography. To date, there is no comprehensive literature review of the radiologic findings associated with various types of female pelvic fistulae, and furthermore, none dedicated to magnetic resonance imaging (MRI). In this article, we seek to provide a broad overview of the MRI characteristics of female pelvic fistulizing disease in combination with epidemiologic and clinical characteristics. MRI is often considered the imaging modality of choice for evaluation of fistulae owing to its superior soft‐tissue contrast and ability to provide surgeons with the highest quality information derived from just one study, including anatomic location of fistulae and associated pelvic pathology. In other instances, MRI can be complementary to the more traditional imaging techniques. This review will describe the etiology, anatomy, MRI findings, and treatment pearls for several of the more common pelvic fistulae found in female patients, including anovaginal, rectovaginal, colovaginal, vesicovaginal, colovesical, and other complex fistulae.Level of Evidence: 5Technical Efficacy: Stage 3J. Magn. Reson. Imaging 2018;47:1172–1184

INTRODUCTION: Despite the increase in residency applications, little change in the information available for review prior to a face-to-face interview has occurred. Asynchronous or one way video interviews (OWVI) may offer a way to collect additional data on applicants. Our objective was to assess the feasibility and acceptability of OWVI and to correlate OWVI performance with in-person interview scores. METHODS: Characteristics of successful residents were identified and OWVI questions were developed using medical student volunteers. Candidates who presented for in-person interviews during the 2016-17 season for OB/GYN (n= 45) and Orthopedic Surgery (n=98) were invited to participate in OWVI with 3 questions and a maximum of 3 minutes per question. Videos were reviewed and scored independently by 2 reviewers from the respective departments using a standardized 5-point scale. RESULTS: Forty-six (47%) Orthopedic and eleven (24%) OB/GYN applicants completed OWVI. The interviewer’s scores of OWVI were within one point of one another 84% of the time. High OWVI scores were correlated with higher in-person interview scores (r=0.26) and higher rank list placement (r=0.33). Sixty-two percent of the applicants were satisfied with the OWVI process. Most respondents wanted additional OWVI questions that would allow them to explain why they wanted to apply to a particular program. CONCLUSION: Asynchronous interviews enabled reviewers to differentiate applicants and their scores correlated with rank list placement and in person interview scores. The process was viewed by participants as a way to humanize their application and this may have potential to help screen applicants for residency.

Objective The objective of the study was to evaluate the utility of urodynamic studies performed before primary midurethral sling placement for stress urinary incontinence in predicting the need for subsequent sling release for voiding dysfunction. Methods The health records of women managed with primary synthetic midurethral sling placement at Mayo Clinic (Rochester, MN) from January 1, 2002, to December 31, 2012, were reviewed. The primary outcome was surgical sling release for postoperative voiding dysfunction (ie, prolonged retention, elevated postvoid residual volumes with new voiding symptoms, or de novo onset or worsening of overactive bladder symptoms). Logistic regression models were used to evaluate associations between potential clinical risk factors and the primary outcome. Results Overall, 1629 women underwent primary synthetic midurethral sling placement during the study time frame, including 1081 patients (66%) who underwent a preoperative multichannel urodynamic evaluation. A sling release for voiding dysfunction was performed for 51 patients (3.1%) at a median of 1.9 months postoperatively (interquartile range, 1.3–9.3 months). Patients undergoing sling release were significantly more likely to have had retropubic sling placement (P = 0.003) and concomitant prolapse surgery (P = 0.005). On univariate analysis, no urodynamic parameters were associated with the risk of sling release; evaluated parameters included peak flow rate (P = 0.20), postvoid residual volume (P = 0.37), voiding without detrusor contraction (P = 0.96), and detrusor pressure at maximal flow (P = 0.23). Conclusions Sling release for voiding dysfunction was rare in our cohort. No urodynamic parameters were associated with the risk of sling release.

Objective The aim of this study was to compare outcomes of vaginal hysterectomy between patients with and without the following perceived contraindications to vaginal surgery: uterine weight greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Methods Retrospective cohort of benign vaginal hysterectomies between 2009 and 2013 was obtained. Outcomes included uterine debulking, transfusion, intraoperative complications, length of stay, and Accordion grade 2+ postoperative complications. For each outcome, the association between the presence of each contraindication and the outcome was evaluated using univariate and multivariate logistic regression models. Results Among 692 vaginal hysterectomies, 11% (76/691) had a uterine weight greater than 280 g, 11.3% (78/690) had no vaginal parity, 14.9% (103/690) had a history of cesarean delivery, and 37.7% (248/657) had a body mass index of 30 kg/m2 or greater; 110 (15.9%) had 2 or more contraindications. Uterine debulking occurred in 146 women (21.1%), and both uterine weight greater 280 g (adjusted odds ratio, 39.2; 95% confidence interval, 18.4–83.5) and prior cesarean delivery (adjusted odds ratio, 2.1; 95% confidence interval, 1.2–3.7) were significantly associated with an increased likelihood of uterine debulking after adjusting for age, hematologic disease, and preoperative diagnosis. None of the contraindications were significantly associated with need for a blood transfusion, presence of an intraoperative complication, length of stay greater than 2 days, or presence of an Accordion grade 2+ postoperative complication, which occurred in 2.7%, 2.5%, 14.0%, and 6.9% of all women, respectively. Conclusions Vaginal hysterectomy can be safely performed with favorable outcomes, even in women with a uterus greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Our findings challenge several perceived contraindications to vaginal hysterectomy.

INTRODUCTION: The number of applicants to Obstetrics and Gynecology subspecialty fellowships is projected to increase; however, it is known that the interview process is taxing for both applicants and the programs they attend. Concerns include excessive time away from work, cost, lack of coordination for regional travel, and overlapping interview dates. Little is known about applicant preferences for interviewing. METHODS: An e-mail link to a survey designed using web-based tool SurveyMonkey was sent to all residency directors for distribution to fourth year residents at ACGME-accredited Obstetrics and Gynecology programs in the United States. RESULTS: A total of 190 residents responded, 138 of whom applied to fellowship in 2016. Applicants were predominantly female (73.6%), Caucasian (78.3%), married (76.7%), and without children (74.4%). Most (81.3%) were from an academic program. Applicants attended a mean of 10.9 interviews; the most common reason to cancel was conflict with another interview (72.3%). Saturday was the most preferred interview day (46.7%). The majority of applicants preferred half-day interviews (93.2%), and 61.0% preferred an 0800 start to earlier or later times. A pre-interview dinner was favored (64.4%) with work restraints being the largest barrier to attendance. Personal days granted for interviews varied by program from zero (16.1%) to greater than 11 (25.0%). Vacation and unpaid leave were utilized by 56.5% and 9.0% respectively. CONCLUSION: Interviewing for fellowship is a burdensome process, but it could be improved by implementing regional coordination, shorter interview days and weekend interview dates. Gathering information from applicants and fellowship directors can help further streamline the process.

Objectives This study evaluated our experience after implementing a pelvic floor rehabilitation program including behavioral modification, biofeedback, and vaginal electrogalvanic stimulation (EGS). Methods This prospective cohort study evaluated outcomes of patients with pelvic floor dysfunction (urinary or defecatory dysfunction, pelvic pain/dyspareunia) who underwent pelvic floor rehabilitation. Patients received 4 to 7 sessions (1 every 2 weeks) including biofeedback and concluded with 30 minutes of vaginal EGS. Surveys assessed subjective changes in symptoms; success was evaluated using a 10-point visual analog scale (VAS) at the final session (10 = most successful). Paired comparisons of responses at baseline and final treatment were evaluated. Results Ninety-four patients were followed up through therapy completion. Treatment indications included urinary (89.4%), defecatory (33.0%), and pelvic pain or dyspareunia (30.9%); 44.7% of patients had a combination of indications. Among women with urinary symptoms, the percentage reporting leakage decreased from 92.9% to 79.3% (P = 0.001), leakage at least daily decreased from 69.0% to 39.5% (P < 0.001), daily urgency with leakage decreased from 42.7% to 19.5% (P = 0.001), daily urgency without leakage decreased from 41.5% to 18.3% (P < 0.001), and median VAS rating (0 = not at all, 10 = a great deal) of daily life interference decreased from 5 to 1.5 (P < 0.001). The median success ratings were 8, 8, and 7 for treatment of urinary symptoms, pelvic pain/dyspareunia, and bowel symptoms, respectively. Conclusions An aggressive pelvic rehabilitation program including biofeedback with vaginal EGS had a high rate of self-reported subjective success and satisfaction and should be considered a nonsurgical treatment option in patients with pelvic floor dysfunction.

Objectives Rectovaginal fistulae (RVF) often represent surgical challenges, and treatment must be individualized. We describe outcomes after primary surgical repair stratified by fistula etiology and surgical approach. Methods This retrospective cohort study included women who underwent surgical management of RVF at a tertiary care center between July 1, 2001 and December 31, 2013. Cases were stratified according to the following etiology: cancer (RVF-C), inflammatory bowel disease or infectious (RVF-I), and other (RVF-O). Patients with prior surgical treatment of RVF were excluded. Surgical approaches included local (seton, plug), transvaginal or endorectal, abdominal, diversion alone, or definitive (completion proctocolectomy with permanent colostomy or pelvic exenteration). Recurrence-free survival was estimated using the Kaplan-Meier method, and comparisons between subgroups were evaluated based on fitting Cox proportional hazards models. Censoring occurred at last relevant clinical follow-up. Factors contributing to recurrence-free survival were evaluated including age, body mass index, smoking status, fistula etiology, ileostomy, and surgical approach. Results During the study period, 107 women underwent surgical repair of RVF. The most common fistula etiology was RVF-I (54.2%), followed by RVF-O (23.4%), and RVF-C (22.4%). Ninety-four women underwent fistula repair by the local (29.9%), transvaginal/endorectal (25.2%), abdominal approach (19.6%), or diversion alone (13.1%), whereas 13 underwent definitive surgery (12.2%). Recurrence-free survival was significantly different depending on surgical approach ( P < 0.001), but not etiology ( P = 0.71). Recurrence-free survival (95% confidence interval) at 1 year after surgery was 35.2% (21.8%–56.9%) for the local approach, 55.6% (37.0%–83.3%) for the transvaginal or endorectal approach, 95% (85.9%–100%) for the abdominal approach, and 33.3% (15%–74.2%) for those with diversion only. Conclusions Recurrence rates after RVF repair are high and did not differ by fistula etiology. Abdominal repair of RVF had significantly fewer recurrences.

Objectives We aimed to determine the rates of readmission and reoperation for patients undergoing surgery for pelvic organ prolapse (POP). Methods The American College of Surgeons National Surgical Quality Improvement Program Participant User File was used to select all surgeries performed for POP from 2012 through 2014. The cohort was then reviewed for unplanned readmissions and unplanned reoperations within 30 days of POP surgery. Patient and procedural factors associated with readmission or reoperation were compared using χ2 analyses and Student t test. Multivariable logistic regression determined independent risk factors for both readmission and reoperation. Results A total of 23,419 patients underwent surgery for POP. Of these, there were 435 (1.9%) readmissions and 341 (1.5%) reoperations within 30 days. Median numbers of days from index procedure to readmission or reoperation were 9 and 8 days, respectively. Those who were readmitted had higher American Society of Anesthesia (ASA) scores, longer operative times, and longer lengths of stay than those who were not readmitted (all P < 0.001). Patients who underwent unplanned reoperation also had higher ASA scores, longer operative times, and longer lengths of stay than those who did not undergo reoperation (all P < 0.01). The most common reasons for readmission were surgical site infection (SSI) (19.3%) and non-SSI (15.9%). The most common reason for reoperation was urologic (27.6%) such as cystoscopy or stent placement. Conclusions Readmission and reoperation rates are relatively low for patients undergoing surgery for POP. Infection, both SSI and non-SSI, accounted for 35.2% of readmissions. Identification of ASA score of 3 or higher, longer total operating time, and increased length of stay is associated with unplanned readmission and reoperation.

Objective The optimal suture selection for mesh attachment during robotic sacrocolpopexy (RSC) is currently unknown. Here, we sought to evaluate the outcomes of RSC using absorbable sutures for vaginal and sacral mesh attachment. Methods We retrospectively reviewed 132 RSC surgeries that were performed for vaginal vault prolapse in the Division of Gynecologic Surgery at our institution from February 2007 to December 2013. All cases were performed with absorbable suture (polyglactin) for vaginal and sacral mesh fixation. Sacrocolpopexy failure was defined as patients undergoing either repeat prolapse surgery or pessary use for recurrent prolapse. The durability of RSC was assessed via Kaplan-Meier method. Results The median age at surgery was 61.1 years (interquartile range [IQR], 55.6–68.2) and the median length of postoperative follow-up was 33 months (IQR, 15.7–57). The median body mass index was 26.5 kg/m2 (IQR, 24.3–29.7). During follow-up, 10 patients underwent prolapse retreatment. There were 2 apical recurrences, 4 distal anterior recurrences, 2 posterior recurrences, and, in 2 cases, the location was unknown. One apical recurrence was confirmed to be secondary to detachment of the mesh from the sacral promontory. Among those with recurrence, the median time to recurrence was 15.5 months (IQR, 4.22–35.9). Overall, the 1-year and 3-year freedom from repeat surgery rates were 96% and 93%, respectively. Conclusions With a median follow-up of 33 months, the use of absorbable suture for both vaginal and sacral attachments during RSC is effective. Further studies evaluating suture selection and mesh attachment techniques for RSC are needed.