Assessment of laparoscopic injuries by three methods

OBJECTIVE: To compare laparoscopic, gross, and fluorescent assessment of laparoscopic pelvic injuries. DESIGN: Experimental prospective study. SETTING: Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio. ANIMAL(S): Nonpregnant adult female pigs. INTERVENTION(S): Pelvic organs injured with laparoscopic energy sources were assessed laparoscopically, grossly, and with a fluorescent indicator and Wood's lamp. MAIN OUTCOME MEASURE(S): Three different measurements of each laparoscopic injury. RESULT(S): Assessment of injuries by laparoscopy did not differ significantly from gross assessment of injuries. In the segments of bowel and bladder that were injured with monopolar cautery, the Wood's lamp assessment of the injuries was significantly longer than the laparoscopic assessment of the injuries. CONCLUSION(S): Laparoscopic assessment of injured ureters, bowel, and bladder appear to be similar to gross assessment of these tissues. In tissue where the serosal surface is intact, the use of a fluorescent dye and a Wood's lamp provides a clear margin of the injured tissue.     

A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy. Presented at the 34th American Urogynecologic Society Meeting, September 4–6, 2008, Chicago, Illinois     

Difference in quality of life in women with urge urinary incontinence compared to women with stress urinary incontinence

Introduction  We evaluated whether women with urge urinary incontinence (UUI) have lower quality of life (QOL) than women with other forms of urinary incontinence. Methods  Patients completed three validated questionnaires when presenting for evaluation at a urogynecology practice and were divided into four groups based on their responses: those with symptoms of stress urinary incontinence (SUI), UUI, both SUI and UUI (mixed UI), and neither SUI nor UUI (controls). Results  A total of 465 women were included: 53 women with UUI (11.4%), 101 with SUI (21.7%), 200 with mixed UI (43%), and 111 controls (23.9%). Overall, there was a significant difference (p < 0.001) in PFIQ bladder scale scores as a function of UI group, with individual mean PFIQ scores of 17.1 for controls, 22.3 for SUI, 32.7 for UUI, and 36.8 for mixed UI. Individually, all seven questions in the PFIQ bladder domain were significantly different by group (p ≤ 0.001). Conclusions  Women with UUI and mixed UI have lower QOL scores than women without incontinence or with only SUI. The project was approved by the IRB at Hartford Hospital.     

Can community-dwelling women reliably identify infected urine?

The purpose of this study was to evaluate whether community-dwelling women can reliably identify infected urine samples. A convenience sample of 25 women judged six urine samples. Of these, two were normal, two contained culture-proven infections, and two were intentionally abnormal because of ingestion of asparagus or vitamins. The women decided if each sample was infected based on its color, clarity, and odor. For the two normal samples, 56 and 96% women correctly identified them. Of the two samples positive for infection, women were correct 80 and 100% of the time. Of the two samples designed to be abnormal, women were correct in 92 and 64% of their evaluations. Using the 150 total evaluations of urine samples, the sensitivity was 90%, and the specificity was 77%. Based on this small sample, community-dwelling women can detect infected samples of urine. However, women should still be screened for factors that might have distorted normal urine. Presented in poster form at the American Urogynecology Society, Palm Springs, CA, October 2006.     

Anatomy of the left upper quadrant for cannula insertion

STUDY OBJECTIVE: To determine the anatomy of the left upper quadrant (LUQ) of the abdomen in women with different body mass indexes. DESIGN: Review of computed tomographic (CT) scans and medical records (Canadian Task Force classification II-2). SETTING: Large tertiary care medical center. PATIENTS: Sixty-three women over age 18 years who had scans performed for any indication. Nine women were excluded because of contraindication to LUQ laparoscopic cannula insertion and five because of incomplete records. Intervention. None. MEASUREMENTS AND MAIN RESULTS: The closest organs to the LUQ insertion site were the liver and stomach. There was significantly more subcutaneous fat at the umbilicus than at the insertion site. A positive correlation was found between body mass index and distance between structures and the site. CONCLUSION: Cannulas should not be inserted in the LUQ in women with hepatomegaly or splenomegaly. Because the stomach is so close to the insertion site, gastric drainage should be performed before cannula insertion. The site is likely safe in obese women whose abdominal organs are far away from it, and who have less subcutaneous fat there than at the umbilicus.     

Laparoscopic repair of ureteral injuries

STUDY OBJECTIVE: To assess the outcome of laparoscopic repair of pelvic ureter injuries. DESIGN: Retrospective case series (Canadian Task Force classification II-2). SETTING: Large urban tertiary care medical center. PATIENTS: Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures. INTERVENTION: Laparoscopic ureteroureterostomy. MEASUREMENTS AND MAIN RESULTS: All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury. CONCLUSION: Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure.     

Anterior vaginal wall prolapse and voiding dysfunction in urogynecology patients

We investigated whether women with and without anterior vaginal wall prolapse have voiding differences. Women (n = 109) who presented to a urogynecology practice were categorized into two groups based on anterior vaginal wall prolapse: stages 0 and 1 and stages 2, 3, and 4. Women with prolapse were older than the women without prolapse but the groups were otherwise similar demographically. There was a higher rate of activity-related urine loss and use of wetness protection amongst women without prolapse. There was no significant difference for urgency symptoms or urge incontinence. Urodynamic testing found no significant differences for maximal flow rate or maximal urethral closing pressures. Postvoid residual volume and detrusor overactivity were not different but approached significance. Anterior vaginal wall prolapse of stage 2 or greater was not associated with urge incontinence or voiding function in this population. Women without prolapse were more likely to report stress incontinence. This was an unfunded study. Presented as a poster at SGS, Tucson, AZ, USA, April 2006.     

Patterns of telephone calls triaged by registered nurses in a urogynecology practice

The volume and time required to manage a nurse telephone triage line in an urogynecology practice can be a concern for staffing, time management, and office patient flow. Therefore, telephone triage logs were retrospectively reviewed for a 12-month period to investigate whether call volume differed on days of the five-day office work week. Results showed Monday to be the busiest telephone triage day, with an average of 32.26 calls per day, and Friday as the second busiest day, with 28.52 calls per day. Based on this review, staffing patterns may need to be adjusted to accommodate the higher call volumes on Mondays and Fridays.     

Left upper quadrant cannula insertion

OBJECTIVE: To determine the safety and efficacy of primary left upper quadrant laparoscopic cannula insertion. DESIGN: Retrospective review. SETTING: Tertiary care medical center. PATIENT(S): Women undergoing laparoscopic surgery for gynecologic indications. INTERVENTION(S): Left upper quadrant cannula insertion. MAIN OUTCOME MEASURE(S): Intraoperative complications. RESULT(S): Primary left upper quadrant cannula insertion was performed 58 times. There were no intraoperative complications. In one woman there was more pain at the LUQ site than at her other incisions. In 12 women (21%) adhesiolysis was performed before insertion of the umbilical cannula. CONCLUSION(S): Primary left upper quadrant cannula insertion is a safe and effective alternative to primary umbilical cannula insertion.     

Surgeon activity in robotic versus abdominal gynecologic surgery

One proposed advantage of robotic surgery is improved ergonomics and decreased surgeon fatigue. The objective of this study is to quantify and compare the physical activity of surgeons during robotic and abdominal surgery using accelerometers. Eight gynecologic surgeons who perform both abdominal and robotic surgery were the subjects of this study. Each wore an accelerometer on the hip during one procedure performed abdominally and during a similar procedure performed robotically. Activity parameters analyzed were average activity counts (AAC) and percentage of time spent in sedentary, light, moderate, and vigorous activity. The paired t-test was used to evaluate differences between robotic and abdominal procedures. AAC was similar between the robotic and abdominal approaches (mean?±?SD: 83.9?±?50.9 versus 79.1?±?37.8 counts/min, respectively, P?=?0.820). The majority of activity spent in robotic and abdominal surgery was sedentary (79.0%?±?5.9% versus 80.9%?±?8.6%, respectively; P?=?0.625) followed by light activity (14.7%?±?3.9% versus 12.8%?±?6.1%, respectively; P?=?0.541) and then by moderate activity (6.3%?±?3.4% versus 6.3%?±?2.8%, respectively; P?=?0.981). None of the activity for either surgical approach qualified as vigorous. There were no differences in activity parameters by surgical approach. Accelerometer data demonstrate that surgeon activity expenditure is similar in robotic and abdominal surgery. Future studies comparing measures of physical activity and strain between surgical approaches are needed to determine whether the robot??s improved ergonomics translates to improved surgeon experience.