Video Presentations
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retention or obstructive voiding symptoms, complex urinary in-
continence symptoms, complicated lower urinary tract surgical
history or conditions increasing the risk for poor bladder compliance
or vesicoureteral reflux. An example of a normal video urodynamic
study is described to demonstrate important techniques and to show
the five points at which images are generally obtained. Examples of
interesting study findings are discussed. Findings include bladder
diverticula, detrusor overactive with leakage, poor bladder compli-
ance, vesicoureteral reflux, stress incontinence, detrusor external
sphincter dyssynergia, open bladder neck, and urethral diverticulum.
CONCLUSION: Video urodynamics has several important advantages
over conventional urodynamics for the evaluation of patients with
lower urinary tract symptoms. It gives the clinician simultaneous
functional and anatomic views of the urinary tract. While this can be
of great benefit for specific patient presentations, the advantages do
not come without potential risks. Financial costs and risk of radia-
tion exposure must be weighed against the benefit. Nevertheless, in
complicated patients, as illustrated here, video urodynamics may be
invaluable in evaluating complex lower urinary tract dysfunction.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Benjamin Smith: Nothing to disclose; Catrina C. Crisp: Nothing to
disclose; Rachel N. Pauls: Nothing to disclose; Steven D. Kleeman:
Coloplast, principal investigator in clinical trial, research grant paid
to research department; Ayman Mahdy: Boston Scientific, principal
investigator in clinical trial, research grant.
5 Various methods of entry into the peritoneal
cavity in post-hysterectomy prolapse
C. E. Bretschneider1, K. Jallad1, P. Lang2, M. Karram2,
M. D. Walters1
1
Urogynecology, Cleveland Clinic, Cleveland, OH, 2Urogynecology, The
Christ Hospital, Cincinnati, OH
OBJECTIVE: To review the key steps involved in the identification of
and entry into the peritoneal cavity in post-hysterectomy prolapse
from posterior, apical and anterior approaches.
DESCRIPTION: There are two main transvaginal approaches for
vaginal vault suspension in post-hysterectomy prolapse: the extrap-
eritoneal approach and the intraperitoneal approach. Entry into the
peritoneal cavity can be challenging in post-hysterectomy patients.
In this video, we will review how to identify and enter the peritoneal
cavity from various approaches – posterior, apical, and anterior. In
summary, to successfully enter the peritoneal cavity in post-hyster-
ectomy prolapse consider the following key points: -Perform a
thorough examination in order to determine the best approach for
peritoneal access: posterior, apical or anterior. -Place a finger in the
rectum during dissection of the peritoneal sac in order to better
delineate borders of rectum, bladder, and peritoneum. -Prior to
entering the peritoneal cavity sharply, thoroughly inspect the peri-
toneum both visually and digitally to avoid injuring important
structures such as the bowel and bladder.
CONCLUSION: In conclusion, this video reviews three different ap-
proaches for accessing the peritoneal cavity in post-hysterectomy
prolapse. We believe that it is important for vaginal surgeons to be
able to safely and confidently identify and enter the peritoneal cavity
from various approaches to facilitate their prolapse repair.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Carol E. Bretschneider: Nothing to disclose; Karl Jallad: Nothing to
disclose; Patrick Lang: Nothing to disclose; Mickey Karram: Nothing
to disclose; Mark D. Walters: Nothing to disclose.
S620 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017
ajog.
6 Vaginal salpingo-oophorectomy: Tips and
tricks
J. Schmitt, J. N. Byrnes, E. D. Hokenstad, J. Gebhart
Gynecologic Surgery, Mayo Clinic, Rochester, MN
OBJECTIVE: The objective of this video is to provide tips and tricks for
successful transvaginal salpingo-oophorectomy at the time of vaginal
hysterectomy, and review the surgical techniques available.
DESCRIPTION: Salpingo-oophorectomy is completed at the time of
hysterectomy in 47-52% of cases. ACOG suggests that the route of
hysterectomy should be not determined based upon the surgeon’s
plan for benign adnexa. Successful oophorectomy with a trans-
vaginal approach at the time of vaginal hysterectomy has been re-
ported to be 65-97.5%. Successful removal of the fallopian tubes and
ovaries necessitates adequate lighting, exposure, and preparation of
the operative field and adnexa at the time of surgery. Various tech-
niques can be utilized to remove the specimen including a round
ligament technique with or without isolated transection of the lig-
ament, or utilizing surgical devices such as a pre-tied surgical loop of
suture, surgical stapler, or an electric vessel sealing device.
CONCLUSION: Salpingo-oophorectomy can be safely performed at the
time of vaginal hysterectomy, and a surgeon’s plan for removal of
non-diseased adnexa need not dictate their choice for surgical route.
The tips and tricks reviewed here can facilitate surgical success uti-
lizing these surgical techniques.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Jennifer Schmitt: Nothing to disclose; Jenifer N. Byrnes: Nothing to
disclose; Erik D. Hokenstad: Nothing to disclose; John Gebhart:
Astora, consultant, consulting fee; UpToDate, author contributor,
salary; Elsevier, author, salary.
7 Recurrent uterine prolapse associated with
bladder exstrophy treated with vaginal
sacrohysteropexy
A. Martinez1,2, R. M. Marquez3,4, A. G. Ochoa3,5, E. D. Estrella3
1
Female Pelvic Medicine & Reconstructive Surgery, Hospital Regional
Monterrey ISSSTE, Monterrey, Nuevo León, Mexico, 2Professor of
Gynecology and Urology, Universidad Autonoma de Nuevo Leon, Monterrey,
Nuevo León, Mexico, 3Female Pelvis Medicine & Reconstructive Surgery,
UMAE Hospital Ginecologia Y Obstetricia, Guadalajara, Jalisco, Mexico,
4
IMSS Centro Medico Nacional Occidente Guadalajara Jal, Guadalajara,
Jalisco, Mexico, 5IMSS Centro Medico Nacional Occidente Guadalajara Jal.,
Guadalajara, Jalisco, Mexico
OBJECTIVE: The purpose of this video is to present the surgical
treatment of recurrent uterine prolapse associated with bladder
exstrophy with vaginal sacrohysteropexy.
DESCRIPTION: Congenital bladder exstrophy is characterized by an
absence of the anterior abdominal wall with exposure of the ureteral
orifices, failure of pubic symphysis fusion, and deficient anterior
pelvic diaphragm musculature. The incidence of pelvic organ pro-
lapse is 18%. A vaginal technique to correct the prolapse may be
preferable in those women with a history of multiple abdominal
surgeries. We present the case of a nulliparous 28-year-old woman
with bladder exstrophy and recurrent uterine prolapse, with a his-
tory of multiple surgeries including: bladder and abdominal wall
plasty, cystectomy, colonic conduit and transvaginal mesh for uterine
prolapse. Physical examination revealed stage II uterine prolapse.
Our approach starts with a middle line posterior incision of the
vaginal wall 4 cm below the cervix and dissection of the posterior
peritoneal sac. Blunt and sharp dissection of the retroperitoneal
space in the lateral pelvic sidewall. Two Breisky-Navratil retractors
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are placed in the retroperitoneal space and three permanent sutures
are placed in the anterior longitudinal ligament at the level of first
sacral vertebra. A mesh, 5 cm wide and 15 cm long, is attached and a
pericervical tunnel is constructed; a 3 cm wide and 15 cm long mesh
is passed through and attached anteriorly with three permanent
sutures. Six permanent sutures in the posterior cervix unify the
sacral and cervical mesh and restore the normal intrapelvic position
of the uterus. Seven months post-surgery, vaginal length is 9 cm with
normal sexual function.
CONCLUSION: The retroperitoneal approach of vaginal sacrohyster-
opexy with a history of multiple abdominal surgeries is feasible in
reconstruction. Functional and anatomical results were acceptable in
follow up.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Arnulfo Martinez: Nothing to disclose; Rene M. Marquez: Nothing
to disclose; Andrea G. Ochoa: Nothing to disclose; Enrique D.
Estrella: Nothing to disclose.
8 Retroperitoneal approach for bilateral
salpingo-oophorectomy
L. Liu, M. Wasson, K. A. Butler, J. Yi
Gynecology, Mayo Clinic, Scottsdale, AZ
Supplement to MARCH 2017 American Journal of Obstetrics & Gynecology
Video Presentations
OBJECTIVE: This video outlines a step-by-step guide on how to
gain simple access to the retroperitoneum while performing a
laparoscopic BSO and emphasizes the importance of performing
retroperitoneal dissection in difficult surgeries that are compli-
cated by endometriosis, dense pelvic adhesions or distorted
anatomy.
DESCRIPTION: The steps demonstrated in the video are as follows:
1. Identify the IP ligament and retract medially
2. Incise the peritoneum lateral and parallel to the IP ligament
3. Develop the retroperitoneal space using blunt dissection
4. Identify important retroperitoneal structures
5. Visualize the ureter
6. Incise the peritoneum superior to the ureter and inferior to the
IP ligament.
CONCLUSION: Many common complications, such as ureteral injury
and ovarian remnant syndrome can be avoided by opening the
retroperitoneum during a laparoscopic BSO.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Lora Liu: Nothing to disclose; Megan Wasson: Nothing to disclose;
Kristina A. Butler: Nothing to disclose; Johnny Yi: Nothing to
disclose.
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