Male Pelvic Medicine and Reconstructive Surgery Fellowship Program and the Director of the National Center for Advanced Pelvic Surgery at MedStar Health. She is also a professor in the departments of OBGYN and Urology at Georgetown University School of Medicine. Additionally, Dr. Iglesias is the current chair of the Advisory Board for the Pelvic Floor Disorders Network at the Eunice Kennedy Shriver's National Institute for Child Health and Human Development. She is on the executive board of the Society of Gynecologic Surgeons as the immediate past president. Dr. Matthews is a professor of urology and gynecology at Wake Forest Baptist Health and serves as the division director and fellowship director of urogynecology and pelvic reconstructive surgery. She is an oral board examiner for the American Board of Obstetrics and Gynecology, serves as an editor for the International Urogynecology Journal and is the co-chair for the upcoming Urogynecology Prologue from ACOG. Dr. Matthews is passionate about education and has received numerous teaching awards. She has extensive experience in transvaginal and robotic surgery for prolapse repair and has been invited to perform live surgery in numerous countries. Dr. Matthews has received multiple awards for excellent inpatient care and has been an annual recipient of top doctors in America for the past 20 years. Dr. Menafee is division head of female pelvic medicine and reconstructive surgery at Kaiser Permanente San Diego, an adjunct clinical professor in Department of Reproductive Medicine at University of California, San Diego. He is lead of Benign Gynecology Robotics for Southern California Permanente Medical Group and research chair for Kaiser Permanente San Diego. He is a co-PI in Eunice Kennedy Shriver's National Institute of Child Health and Human Development's Pelvic Floor Disorders Network. His academic interests continue to be surgical innovation and efficacy and evaluation of large datasets to answer important clinical questions. Thank you, Drs. Iglesias, Matthews, and Menafee for being here tonight and serving as our expert panelists. A couple of reminders before we get started. The presentation will run about 45 minutes. The last 15 minutes of the webinar will be dedicated to additional Q&A. Before we begin, I'd like to review some housekeeping items. This webinar will be recorded and live streamed. A recording of the webinar will be made available in the Oggs e-learning portal. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions. We'll answer them throughout the presentation. Use the chat feature if you have any technical issues. Ogg staff will be monitoring the chat and can assist. All right, so we'll go ahead and get started. So for our first case, this is a 39 year old female who presents with vaginal pain and bulge. She has a history of a vacuum assisted vaginal delivery complicated by a second degree perineal laceration. Over the last two months, she has noticed a hard tender mass between her vagina and rectum that has increased in size. Her exam displays a right-sided perianal three centimeter fluctuant tender mass. There's no vaginal discharge present. An MRI is ordered and she's referred to colorectal surgery. MRI displayed a three by two centimeter ill-defined enhancing lesion in the right perineum favoring a region of phlegmon. Internally, there are at least three foci concerning for small abscesses, the largest measuring one centimeter. There's no definite communication with the rectum, anus or vagina. The area of phlegmon abuts the right levator ani muscle and colorectal surgery declines to operate and sends it back to urogynecology for management. So Dr. Menafee, if you don't mind starting just talking about what your differential diagnosis would be for this patient. Yes, Sarah, thanks. And her delivery was when? Well, it was remote, about 12. Remote, okay, that's good. You know, this is one I, you know, I said it's not a Bartholone's, right? Because we know that those can get kind of botched up and confused and people can get into a lot of trouble when that Bartholone's cyst or abscess. I look at this and say, I think she's got some anal rectal disease given the abscess. I don't feel real comfortable without a source because typically we find that when there's an abscess, especially a perineal abscess, there's a reason for an abscess. So I'm gonna be a little concerned with, you know, a fistula that's unrecognized. You know, if you just said it was right after delivery, is that kind of a fourth not recognized or a suture granuloma? I always worry about with abscesses without a source. Is this a Crohn's and has she been worked up for that? So that's kind of what I'm starting with. It's not a Bartholone's, right? Two, it's anal rectal disease or an abscess until proven otherwise, and where's the source? So that's gonna kind of be my differential and the workup's gonna kind of stem from less finding a reason for this abscess. So I'll start with that and let everybody else pipe in because I still don't know what it is. Perfect. What about Dr. Matthews, Dr. Iglesias? Anything else you'd include in your differential or kind of start with the workup? Well, you know, I recently was in a case like this who'd had a copepaxi and peroneurophy, and she presented, you know, very soon after surgery with similar complaints and was diagnosed at a very preeminent medical center with bilateral Bartholone's. And I think that Bartholone's are not normally what it is unless they're in this very classic location that is really more on the vaginal side. And I think that your differential diagnosis was great. I mean, it's unfortunate that colorectal was not willing to take the patient to the OR because it's cryptoglandular disease. I mean, that's just what it is. And these are very difficult to find and treat. They need a good exam under anesthesia. I mean, you're welcome to give her a course of antibiotics for a period of time and see if it resolves spontaneously, but it's not going to resolve spontaneously because it formed spontaneously and there's something seeding the source. Remotely, I have seen rare suture granulomas, but these are more classically more superficial in the perineum, and they are not deep to the levator ani. So I think that this is something that's unfortunately tracking from a small opening in the rectum that would be identified with a careful exam under anesthesia and managed with acetone, let the tract mature, and then see if it can be surgically excised. And then I would say just for the exam, I mean, we don't go from hearing the patient talk about this mass on her perineum to getting an MRI. I just need a better physical exam. Like let's start with our digital rectal exam. Is the sphincter intact? Do we have a small fistulas channel that we can even see and put a little lacrimal probe in there, get a little of that KY jelly with some little blue stuff that you put onto it and kind of press it just to see? I mean, could be that she has inflammatory bowel disease, but could there be a small hole that really this wasn't a second degree laceration or a small pinpoint something or other? So for me, if someone were to present this with me, you know, I would want a little clearer physical exam just with my finger and the anus. All right, perfect. And an anoscopy might be beneficial too. Wonderful. Yep, we have those little anoscopes here in the office as well. Fabulous. And you might need to put them in like the knee chest position sometimes, you know, rather than in lathotomy because you get a clearer view looking down rather than having to look up, strain my neck. I'm really impressed, Cheryl, that you have an anuscope in your office. I don't have one in mind, but I think that this is the kind of patient that, you know, is really well served by a joint approach with a good exam under anesthesia, which is probably what it's going to take to figure it out. And the last differential we didn't say is a different or another colorectal surgeon. All right, perfect. Let's go ahead. We can move on to our next case. Oh, I forgot the pictures. Well, you're going to tell us what the final thing was? So this patient, without any further workup, she did end up going to the operating room. She had an IND that was done it was an abscess that was there. And then the decision was to let it heal by secondary intention. So no fistula connection was found. Just one little point is that when you have an abscess in that area, I mean, it likely needs to be drained or it will become a fistula. So just, you know, that's kind of that anal rectal abscess. Stage one is the abscess, stage two is the fistula. If there's not already one there. And I'm glad they let it heal by secondary intention. Blah, blah, blah. Yeah. All right, let's go on to, we can skip and go to case four. All right, so this is a 72 year old patient who presents to your office for a current vaginal bulge. Surgical history is significant from abdominal sacrocopexy 14 years prior and a robotic assisted sacrocopexy one year prior. She has constipation and reports a bowel movement every two to three days requiring significant straining. She recently started using psyllium fiber with improved constipation and a daily bowel movement. The case was discussed with colorectal surgery who did not have any further recommendation for constipation management. And so our exam displays, you know, our anterior points are coming to plus four, her apex is to minus three. Let's see, Dr. Matthews, if you can kind of talk about first how you would counsel this patient regarding her recurrent prolapse. Sarah, thanks and happy holidays, everybody. I love this case because I think it's a common in the trenches situation. And as we're seeing more copopexies done for index procedures, we certainly see, you know, in the course of someone getting older, the possibility of recurrence. I try to figure out in my mind where is the failure? Is it a surgical failure? Is it a patient failure? Is it a combination? And where is the specific defect that I need to address? And in this particular case, when I look at her POPQ numbers, the apex is a problem still, despite these two significant apical operations. And that seems to be what's contributing to this distal anterior vaginal wall support loss. I certainly have seen cases where C might be minus eight and you have this distal anterior vaginal wall support loss that is really because the distal compartment of the anterior wall that is beyond a significant anterior mesh is still prolapsing down. So in this case, you know, I'm concerned that the apex is minus three. And so I have to ask myself, well, is it because the person who did the repeat copopexy didn't do a good job? Did they use the wrong materials? Did they not dissect much of the vagina? Was it difficult as a consequence of adhesions from the first operation that precluded the opportunity to do a really good second copopexy? But you know, the person did the operation well, according to the operative note, and they used materials that seemed to be the right materials, not like two sutures at the vaginal apex with Vicrol. You know, I would then say, gosh, you know, why is this failing? And how could I approach this differently? My choices, of course, are if it's distal support loss to a well-supported apex, I might approach this transvaginally, where you can do a placation and a reattachment of the transverse pubocervical fascia to the apical mesh. But in this case, when there really is involvement of the apex, you know, I'd have to think about, could I attach the apex in a different way? Would she be somebody that would be an anterior approach to a sacrospinous fixation? Would I think about introducing a vaginal mesh? I don't know. And I'd have to think about what I saw on exam and what I really thought the cause of failure was if I was going to consider using a vaginal mesh. So those are my thoughts about her. Perfect. What about Dr. Menefee, Dr. Iglesia, any other thoughts? And I just want to super quickly say, this woman is sexually active and that's why I'm not even talking about coprochiasis, but that would be the obvious choice if somebody was not sexually active in 72 after these failures. Well, I think one of her biggest risk factors potentially, and I agree with Catherine, these are the kinds of cases where you actually do have to pull the operative reports. Let's just see if they just use tackers or if they did all non-permanent sutures on the sacrum, anterior longitudinal ligament, stuff like that. I mean, obviously that's necessary, but she does have this constipation issue. And that probably is a big risk factor for her to recur, even if you do something else again. I mean, failing one copropexy, but failing two. So I think that that's going to be really important to get the whole workup for GI motility. And you know what? If colorectal has no recommendations, go see gastroenterology. So we have patients who are GI motility specialists. I mean, there's so many medicines, I can't even name them right now for getting things to get going. You might even recommend the Squatty Potty. Dr. Gutman loves recommending the Squatty Potty. I don't know if it works or not, but throw the kitchen sink at this because I don't think we have a lot more options for her. But if I were concerned, and I saw that she had a lot of prior adhesions and it was a difficult surgery, blah, blah, blah. And now you've got mesh on mesh. I mean, I do think that this is maybe a case where the vaginal mesh kit would have been helpful, because then we've got the anterior and the apex in a new plane potentially to solve this problem because she has a high risk for recurrence and it's an area that hasn't been operated on before. So we would have to bring up something like an uphold or fashion it somehow to the bilateral sacrospinous. That is an option for me to consider as an off label use. I don't know, Sean, what do you call that? I know. You're going to have to pre-fashion it. Yeah, I call them potholes, poor man's upholds, or we just cut it ourselves because you can't get them. This is the kind of example of is a sacrocopexy, is a sacrocopexy, is a sacrocopexy, right? There's so much people doing the same procedure so differently. And I agree with Catherine is that what happened? And I really, this is always intriguing, especially if you did those, you always want to go in and see what failed. However, that's the definition of insanity, right? If she's had two good sacrocopexies, you don't keep on doing the same thing and thinking you're going to get a different result. But the transvaginal mesh, if there's a lot of anterior mesh that's laid down, it's really tough to get into that plane. If there's mesh across it, if it's just a top of the apex sort of sacrocopexy, it's really easy to do it. And then even though we don't do these much anymore, but those paravaginal pairs with a little allograft or hammock, that's where this either mesh or allograft test where this might come in handy given that she's had two failed sacrocopexies that you think are performed with the right equipment and the right surgeon. It might be just in last maybe you're getting those colorectal surgery consults for the abscess sent back because you're sending colorectal surgery constipation. I think that's a no-no unless you're going to get a colectomy or a partial colectomy or colostomy because they don't, at least mine, don't want to see routine constipation. But they would if it was someone who had a transit time and there was a part of the colon that was literally inertia, nothing moving. Oh, they would love that because then you can, you know, reset. Right, right. But to put them on fiber and that's alone, the GIs, we're going to do a better job with that, I think, than management of the constipation. Well, I'm seeing a lot of recurrences after colopexy is in people who've had supracervical hysterectomies. And I very much recognize that it's a method that decreases the risk of mesh exposure in the vagina, but in a big ballooning antivaginal wall prolapse, it is difficult to shorten the antivaginal wall when the cervix is still in place. And we, you know, we just, we see a fair number of these. And so I do think in that circumstance, a repeat sacrocolopexy can be very effective, but at the same time, operating transvaginally and then shortening the antivaginal wall and reattaching that to the apical mesh can also work very effectively. But that is the most common scenario, not exactly applicable to this, because I see this person does not have a cervix, but if they did have a cervix, I would be thinking about how I could shorten the antivaginal wall. And that's a great point. I think another, you know, talk that Catherine and I can kind of duke it out as far as how do you make those supracervical hysterectomies and sacroplexies work? And I do think that's something that techniques that many of us have kind of refined because we do see that anterior wall or did initially. And so we did something in order to kind of shorten the anterior compartment and also the attachment of the cervix as far as where you place it on the mesh. We have a comment in the chat that I think also would be a good discussion point. So, the comment is saying that it also seems that no matter what repair she gets, some attention would need to be paid to the genital hiatus as this might be contributing to recurrence. So, I don't know if one of you could speak about, or Dr. Matthews, if you want to take that one, would there be anything you would consider specifically as part of your repair to address that? Yeah, you know, I do believe the data out of Duke that have showed a strong association of recurrence with a GH greater than four at the end of the case. That's not corroborated by multiple other studies, but I definitely think that the wider the aperture at the introitus, the greater the chance of subsequent prolapse. And so, this is something that we, you know, once we've done our assessment for tensioning of the mesh, the other thing that I look at at that same moment, I leave the console, I personally always come and assess for tensioning, and I look at the size of the GH after doing the rest of the work. And you know, if it's more than four centimeters, we will do a peroneurophy. It's not deemed, it's not been found to be cost effective prophylactically at the time of copopexy. And so that's the, you know, that's the downside of doing it. And there probably will be some cases of dyspareunia that result, but if you've got somebody who's at high risk of recurrence, I do think it's something that needs to be addressed. All right, perfect. Any other questions from the chat, Katie, before we move on? No, no other questions right now. Okay, perfect. I have a comment. I have been in this situation, okay, and then we decide, because we reviewed the op report and it was not that great of a sacrocopopexy that was being done, and there were attackers, and then the question is, when you go in there and you've decided to repeat the sacrocopopexy, how much mesh are you going to remove from the prior mesh? Because now I've got like layer upon layer. And if you've been in that situation, maybe you'd be able to see exactly where it broke off. I mean, obviously if it broke off at the sacrum, and I saw we had one recently, and where it was attached was almost like on the mesentery, it was nowhere near, and it was sutured, but nowhere near the anterior longitudinal ligament. So I couldn't save it, we had to replace it, but many times it's just too much to try and remove that. I remove it when it's bunched up and causing a lot of pain, and then I just have to lay it on top. But I'm just wondering what you guys, if you've had the situation and going on on repeats, because I know you guys have been there as well. And it could be even with an erosion and trying to handle that, trying to take that out. Yeah, Cheryl, I think that there are two separate things. One, if I'm going to repair a D, if I'm going back for a repeat copopexy, it's very rare that I'm putting mesh on mesh, because usually the area that's failed doesn't have mesh on it. And so then I'm trying to extend mesh, and invariably it's pulled away from the vagina. Not every time, but most times it's pulled away from the vagina. And so I'm going to be putting a mesh patch and reattaching that to whatever's intact, if it seems to be well intact at the apex. I have certainly seen circumstances where the sacral arm of the mesh seems to have significantly elongated and stretched. And then I worry about ultra lightweight meshes stretching in that area where it's not double ply. And so in that circumstance, you can even kind of accordion it to bring it up so that it's reupholstered to the promontory. I've not typically done a mesh overlay of a sacral arm on top of a sacral arm that's still intact. And then times when I've had to do mesh excision, I've typically excised the area that is exposed on the vagina. And you can usually find the area of transition from fibrosis and inflammation to where it looks fairly normal. And I've tried to resist excising normal appearing lightweight mesh, which behaves very differently than the old meshes where you had to take the whole thing out. And I think that more harm can come from digging around the sacrum if the mesh does not appear to be fibrotic and infected in that area. I realize we're sort of off topic from the case, but redos, these circumstances do come up in the redos. And so what I've seen sometimes that the meshes were not retro, we peritonealized, and there was like flopping there in the, you know, in the peritoneal cavity, and it may be attached to the anterior wall. But you're right, Catherine, we are reopening up, dicing up your, you know, the pelvic sidewall, creating a new plane, and then putting a layer of mesh anteriorly and going further down lower, because it was more like a super cervical portion just at the top. And then coming alongside it, and maybe, you know, the poster wall is totally fine. I'm just saying these are, it's interesting, because I think we have, each one has to be individualized. But if I had decided to do that, I would be thinking about all these different things, and you know, clearly looking at the mesh burden at the level of the vagina for somebody sexually active. Yeah, I think that's the key. You don't decide what you're going to do until you get in there. These are all game day decisions, and seeing what you have, and what's the most off, how far you can go down. But I agree, if it's normal, and it's incorporated, leave it alone, use that to your advantage, and take care of where it's broken. Perfect. All right, we can move on to the next one. Okay, so this is a 75-year-old with overactive bladder, whose status post sacro neuromodulation stage one, two weeks prior. She was prescribed ceferoxime post-operatively for prophylactic antibiotics to prevent against surgical site infection. Three days before a scheduled S&M stage two, she presents to the ED with frequent foul-smelling watery diarrhea, and she's diagnosed with C. diff. Prophylactic antibiotics are stopped at that point, and she started on fidaximicin for seven days. Let's see, Dr. Iglesias, if you'll kind of talk about timing for stage two, and maybe a little bit about, you know, prophylactic antibiotics for this patient. So I'm assuming, Dr. Ashmer, that the stage one was actually working, and had she not gotten C. diff, this would have been a chip shot, just go ahead and implant the IPG. Unfortunately, you know, this is a situation where I think it's not a good time to be putting in a $25,000 implant and a lead, and I think we have to cut our losses and remove it, stop all, you know, give her the stuff that you need to treat the C. diff, because that can kill you. And when you re-implant, just know where it is, and, you know, hopefully you'll get the same response, and then do a stage one and two together, and I like those, I know that some of my partners are like, I like those little pockets that you put the IPG in now, some of the companies have them, and they're antibiotic-impregnated, so I do not give antibiotics for two weeks after placing this. I think there's controversy as to how long. At the same time, I'm really not doing these stage ones. I basically do bilateral percutaneous leads, and for a week, maybe two, if it's retention or fecal, but usually you'll know if it's going to work, I pull the leads in the office, and then whatever side was best, I do the one and two together, and I do the pocket, and then maybe at max, three days of backdrop, but not these big guns, because I worry about C. diff. C. diff will kill people, it's complicated, but that's how we used to do it, when we did these stage ones, and they're hanging out of your body, particularly for like two weeks. I don't know, how are you guys doing it? So this is something that I really don't like a lot of antibiotics, and we've really struggled, if you look at C. diff, especially in this older population, perioperative antibiotics itself, a little less than 1% will get C. diff. If you give perioperative antibiotics an additional seven days, or God forbid, 14 days, that rate really goes up to about 3%, a little under, so I mean, it's there. So I think that's one of the issues as far as what to do, what type of antibiotics to give, we can always talk about that also. One thing I do, though, when somebody has a successful stem, whether that's three days or seven days or 10 days, I sterilize the wire, I lift it up, and I cut it, and it goes underneath the skin, and that's what I would do with this one, if she had a good functional lead. They don't get infected, it allows you to bide your time, and with this young lady, the recurrence of C. diff, especially if you're giving perioperative antibiotics, with her next surgery, you don't want to really operate on them within eight weeks. The recurrence C. diff for older, 65 and over, is over 50%, so you just got to watch out with that, and how long to delay, I think that's it. There's also these kind of new, we'll see if they have any legs, these lead-only, whether it's the tibial or in the back, those technologies might be out, and those are kind of one placement, and then you just do a transcutaneous stem, and we'll see if those are good options here moving forward, but yeah, I think this is really an interesting case, and kind of gets back is that all antibiotics are not good. We know that with UTIs, and we know that with C. diff, especially in this age group, and you know, even getting bold is that, you know, for the second stage, if somebody's at risk, or it's a recurrent recurrent, you know, what antibiotics do you give at perioperative? God forbid, the infection rate with required X-plant for saccharin modulations, about 6%. It's not super high. If you have a rate of C. diff, would you actually even consider not giving any antibiotics perioperatively in a very high-risk patient? I think that's a little bit more debatable, but we could talk about that too. Yeah. It's a great case, it's another practical kind of in the trenches situation, and I was so grateful that you gave this to Sherelle first to discuss, and I, you know, I must say that I think it's a good lesson for all of us that, you know, P&Es probably is really the right thing to do for patients, and that does give us the opportunity, but I think people are probably giving antibiotics for P&Es, and so it may, it may sort of make us all better stewards to just talk about this and say, you know, can we withhold to the greatest extent possible, certainly for someone with fecal incontinence or neurogenic bladder, maybe you avoiding dysfunction, maybe you feel like a stage one implant gives you a better potential response, and so in those circumstances, it may still be very reasonable to do a stage one. So I think that this is a practical real-life situation in terms of what to do in this particular case, you know, you've got to make a decision about this lady, is she really sick with C. diff, in which case she's certainly not going to have any kind of anesthetic intervention and have a stage two. If she's not very sick and just had a little bit of diarrhea and is now getting better on her Fendazoxin, whatever that antibiotic is, I've not heard of that, I haven't used that, we, you know, typically use Flagyl or oral vancomycin. And I think I would, if she had a really good response, I would give it a try, I would put in the stage two without any other antibiotics, she's already on this antibiotic, and see what happened, but I would give her the choice. I think the most conservative thing is to pull the lead, but you know, to pull the lead, you're going to have to give her a little bit of anesthesia. So I think that you're, you know, you're a little bit between a rock and a hard place here, a rock and a poopy place really. And so I think that I would probably take my chances and put the stage two in if she wasn't really sick from the C. diff. And at least I think this patient, she wasn't very sick, so went ahead and put it in the stage two. Again, did she get any antibiotics? You know, she had a, the antibiotic pocket was used for the IPG, and then she did get Bactrim in addition afterwards. I believe. That was really brave to give her the Bactrim. Wow. Okay. Yeah, maybe we don't need any antibiotics, we just use the pocket, but I don't know. If you've had one of these pus out, you feel really upset because it's like $25,000 that you just throw in the trash can. So I get it. Yeah. All right, Katie, any questions from the chat with this one, or should we? Nothing specifically with the chat, but I wanted to clarify, Dr. Iglesias, you mentioned that you would probably just take out the lead and then go back in later with the full implant. How long would you typically wait to go back in, in this kind of a case? I think, I mean, assuming she responds to the antibiotics and does really well, I guess I would have to check with her ID and use the pocket. I probably wouldn't give any antibiotics and, you know, if the surgical wound site and everything is fine, I don't know, six, eight weeks, something like that. I don't know. How long does it take to, we, who are the microbiome experts? How long does it take to re-get your bowel microbiome back after C. Diff? Might be a year. No, it can. I mean, the conventional wisdom is at least eight weeks, as long as you can wait, you know. Obviously in older people, avoid fluoroquinones, they're more likely to cause C. Diff. Also protein pump inhibitors, probably increase the risk and put everybody on probiotics, especially these people. I love Botox. Who put that up there? There are a couple of questions that just popped up too. The first one was, would anyone consider switching to Botox or to another therapy? I think. Depends on how long you're going to put them on antibiotics after their Botox. Right. But of course. Yeah. I mean, you could. And, you know, I am really a fan of cutting wires. I've been doing that for about 10 years. And I do think it, it, it avoids taking out a, well, five, six, seven, eight weeks. section. Her surgery was complicated by a two centimeter cystotomy in the dome of the bladder that was recognized and repaired intraoperatively. Her Foley was kept in place and CT cystogram two weeks post-op demonstrated a contained leak from the right bladder dome. Management with a Foley catheter was continued and repeat CT cystogram one month postpartum demonstrated a new small vesicle uterine fistula and the patient desires to avoid surgery. So let's see Dr. Menefee, well do you talk about you know conservative management options for this patient? Obviously it depends on her symptoms right. There is kind of several you know reviews and case studies showing the use of deprolupron to be corrective and a lot of these patients it's kind of the symptom profile right. Many of them have urine through their vagina and that's that kind of workup that you know where's the fistula and that could be real difficult and you got to keep that kind of index of suspicion there which I think sometimes you see that these are quite quite a while that they're not diagnosed and then you have this kind of cyclical you know hematuria that you see. So you know it's kind of those telltale signs. So I do think it's worthwhile especially it says she wants to avoid surgery. It's kind of how much surgery but again deprolupron making main menorrheic I think the best and then symptoms as far as how aggressive you get after that right. I mean yeah you is doing it you know assisto finding out where it is and and doing some of these really low percentage procedures. You could always consider that you know fulguration and those but they're not likely to work typically to take care of it. It's a it's a robotic or an open surgery and and we have to excise both the bladder and the uterine size and those those are tough surgeries at least they've been in my experience to get down to the space and dissect them out and one to keep their fertility very often. So hysterectomy is not an option for you but that's where I would kind of go with this. You know I'm sure I was wondering to know do you think to induce amenorrhea is is GnRH agonist necessary or could you achieve the same thing with continuous birth control pills? Is there something special about a GnRH agonist and the effect on the endometrium versus just a continuous OCP that makes someone amenorrheic? I don't I don't know. I don't think there's a difference. It's just you know when you're talking about the timing and the bother right if if they're low bother and it's really just kind of the hematuria you have the diagnosis and I think birth control pill there if they're having a lot of you know urine leakage then I think you kind of go with the Depolubra but it's a side effect profile too right. So I think either one I mean that's the end result that's how we think it works right but I think a lot of it depends on the size of the fistula too frankly and you know what was the factor was it this small dome was it a uterine rupture was it a big you know placental issue and and the size of the fistula as we know with all fistulas. Yeah I mean other ideas for conservative and God bless this woman she's 41 she has a baby hopefully the baby's healthy and she's a real warrior mom so what I would say that if people want to avoid surgery there are a few case reports of fiber and glue being used in these situations if they're teeny tiny and maybe that'll bite her sometime. It's almost a part of me that wants to try some bulk of it in this situation. Anyway the other thing that I would say is for the leakage and if it's not that bad people have used like diaphragms or the menstrual cups you know to collect the fluid and use and and you know empty that on a regular basis and you know she's breastfeeding whatever until it's time and then when it's time to fix this it is easier if you are doing hysterectomy at the same time but if for some reason you want to keep the uterus the key to this because sometimes these tracts can be so circuitous is to like stent it with a guide wire they're either coming in laparoscopically and kind of pulling it down through it out of the cervix and then as you're coming from above you'll be able to get right to your guide wire. I've actually also used flexible hysteroscope and helped me guide that into the place because it was easier with the flexible like a two miller coming in from the uterine side and sticking it into the bladder as we're dissecting you know someone from above and below but that you know and it's someone who wanted to keep her uterus and we really wanted to be able to find this track etc etc so those little tips and tricks could be useful when you decide to to fix this but in the interim if it's small maybe there's some bulking or some fiber and glue or something that you could try I don't think it's going to hurt. Yeah I think that for this patient I would try a combination of cystoscopic fulguration from the bladder side and continuous birth control pills to decrease the excursion of menstrual fluid across the tract. I think it's really difficult to tolerate as a 41 year old being on a GnRH agonist for six months and if continuous birth control pills which are which there are a couple of case reports if it works I think it's worth trying that. I gosh I've got a family member who's come to visit and they're like trying to get into my door so we'll see if I can save them off. The other thing that I will say about these fistulas is if something's connecting to the uterus you know Cheryl you mentioned the word transvaginal and I'm not brave enough to tackle these transvaginally I think this is a really wonderful opportunity for robotic or laparoscopic work and we just really you know the dome of the bladder is your friend opening that up you know doing a transvestical approach cutting down to the tract you can really see what's involved and you've really just got to separate the bladder from the uterus and I think the uterus is the complicated side of this whereas the bladder in this circumstance I'm happy with the friendly dome of the bladder and I'm going to use that and these are typically higher in the posterior wall they're not down in the trigone and so I do think that you know using your skills from above in this circumstance if you do if they are continuing to be symptomatic after the things you've tried that are conservative I think it's worth doing that. Perfect and this patient from what we were told is that they did she did get Lupron and it did resolve this vicious track which was great. Okay maybe we can do one more. But Katherine open the door. Oh no I need to torture these people they're gonna stand outside. It might be fudge. Let me um no they're there they're there. Everyone's gonna get coal in your stocking. You know that's why I have my little nephew's coming because you know it's Christmas time and so I was like well I'll be with you in just a minute. Anyway my husband's going to come and rescue the situation but let's talk about case eight. Perfect so this is a 44 year old P2 with a history of hemochromatosis, cirrhosis, liver failure and ascites and she presents with vaginal bulge symptoms. She's undergone multiple paracenteses and reports severity of her prolapse is directly related to the ascites accumulation. Office exam displays stage 4 uterovaginal prolapse and she has a PVR of 270 cc's. She's unable to be fit with a pessary in the office and she's awaiting a liver transplant. So she has elevated liver functions, elevated bilion INR and she had a renal ultrasound that showed a mild to moderate hydronephrosis bilaterally. Let's see Dr. Iglesias do you want to start with this one and kind of talk about your counseling and management options for this patient. Right this is this is hard and I've had these cases we have people on the transplant list and you know the last thing I think you want to do is enter the belly. Everything that you do on this case should you're just going to be causing a whole lot of hurt. If you do a colpotomy and all that ascites comes out it's just gonna it's not gonna be good and with the bleeding so you want to stay extra peritoneal. Now there's a couple if you do like a sacrospinous hystereopexy potentially if you can get her coagulation status that's an option that's with the uterus in place you may need to do it bilaterally speaking. I mean there are even ways that you can if it's so bad and you're gonna have such bleeding and they say that she's too high a risk blah blah blah you can just shorten the perineal the genital hiatus with a kind of more aggressive perineoplasty so she can use a pessary so that the hydronephrosis and things that are you know could be settled and we can work on her function. You know for me she is a waiting liver transplant quality of life is really important maybe she wants to be sexually active I want to have that conversation so I can understand because then I would maybe want to pick doing a something extra peritoneal prolapse repair versus like something at the perineum you know something like a perineoplasty that's a little aggressive or even levator fication it would it would sway me on based on her sexual activity and her desires for intercourse and stuff like that. But I would not get in not even any colpotomy enterocortisac post none of it. Perfect how about Dr. Menefee, Dr. Matthews any insight with this? Yes she she needs to get her liver transplant have her ascites drained a little bit more often. You know these are you know if you look at her kind of child cue score and we don't have all the data but she's up to you know a B high B or a low C for intra-abdominal surgery that mortality rate is it depends but somewhere around 50 to 80 percent for a C. So you've got the anesthetic the portal hypertension the varicosities that you got to worry about. So this is one that you know I want I think she needs to wait you need to manage it best you can and God forbid if you have to operate her on her one we need to make sure she's in her hydros better so is that a catheter or self-cath and if anything I agree with Cheryl it's a local it's you know it's maybe just an aggressive paranorphy to keep something to hold the pessary up till we get her her liver transplants. You know the these patients are really difficult right because the transplant thing could be you know a long time and I think that what she's demonstrating is that she's got compromised renal function as a consequence of this big prolapse and so there's a legitimate need to do something and I do think here everyone's you know commentary of remaining extraperitoneal is excellent. You know these people do tend to while her iron are is normal and I'm very grateful that someone had the foresight to present those labs because what you really are terrified about is getting into some hemorrhage situation for this patient which is real the tissues are going to be probably edematous and you know it's going to be more difficult to obtain hemostasis but I definitely would try in a case like this to do an aggressive hystereopexy with anterior and posterior repair. It's not going to be the operation that's going to be you know worthwhile for the rest of her life but the rest of her life could be relatively short and if she gets a transplant and then it's healthy well then you can do you know another operation but we've had really great results from my hystereopexy. We love an anterior approach when there's also significant anterior wall prolapse present and I think that it's something that you very much need in your toolbox. We tend to do it unilaterally because the cervix doesn't stretch across to both sacrospinous ligaments unless you have a mesh bridge in between and this is a case that you know would you consider using you know a mesh to the sacrospinous ligaments maybe but I don't know I think that in someone like her I would go with my straightforward hystereopexy. I don't think an extraperitoneal uterus sacral will be enough like a Manchester type procedure. I don't think that'll be quite enough for a stage four prolapse but I think on the basis of a hydronephrosis if she really is medically maximized in terms of things that can be done to reduce her ascites I think you're kind of forced to offer her an operation under the least anesthetic circumstances possible. I would do this with some blood available. I mean I think she's got a much higher risk of bleeding too which is something to consider. What do you guys think about going completely through all the vaginal layers and you know they have new devices out that we can do uterine suspensions and just avoid all incisions. I even thought about that you know it's not something that I do on a regular basis but we do a lot of sacred I mean I you know sacrospinous and kind of visualize and use capia but there's newer devices where you can just kind of dart it right through all the layers of the vaginal epithelium and just kind of pin it up onto the cervix with the sutures being inside the vagina and they're permanent but they're able to be removed. I don't know there's I just you know you want to get out dodge I'll probably have the least amount of bleeding assuming you know where the pudendal is and stuff like that. I mean those are in I've not used those they're intriguing they're probably a 10-minute surgery. Again what worries me the most with her is her ascites and the pressure talking about the constipation person earlier. I just worry if the ascites is not drained regularly or taken care of she's going to blow through a you know a suture based a single suture based attachment. If she doesn't blow through that the rest of it's going to stretch out anyway. Well I'm just saying use support the uterus put a cupessary in there open up close the close the thing get out of dodge and then get her medical managed. I don't know that's what I would do like I'm just trying to think of doing the least harm but controlling the problem. But you know I think we've all seen these patients it's an unfortunate thing having that much peritoneal ascites. Yeah we're getting a few questions in the chat I think about more conservative management or non-surgical. So there were some questions about considering tips or more frequent paracentesis and then also about potential approach to catheterization like considering an SPT or percutaneous nephrostomy or would you do more intermittent catheterization. So speaking about one of those. But there's a dual reason I mean you know when someone has stage four uterine prolapse and in absence of ascites and we've done a systematic review on this the risk of hydrourea nephrosis is six to thirty percent and I've even had cases I've been around so long where the patients literally have lost their kidneys and you have you know dead kidney function. So I don't know that a suprapubic tube is going to resolve that because the uterus is still hanging out and causing you know the kink on the ureter. So but I do agree that if we could reduce the prolapse and decrease the ascites that would probably have a significant effect whether or not you do continual peritoneal drainage or what the special I don't know. My father-in-law had one with the stomach cancer it's a blessing to have but it is very difficult to be draining leaders and leaders daily. So. I don't know what tips is so if whoever would like to educate me as to what that is that'd be great because if maybe this maybe is a great suggestion I just don't know what that is. Portal vein shunt. So that's from my smart colleague Amr Al-Haraki. So I don't know I mean that sounds like a great idea. It's obviously not going to change the fact that she has prolapse but the patient does say that her severity of prolapse is directly related to ascites accumulation. If it's not a tense prolapse it may be that in those circumstances a pessary would stay in. It sounds like when it's tense that it's just too much pressure. So I don't know how often those portal vein shunts are put in. Well perfect. I think we've run out of time. So on behalf of the AUGS staff I'd like to thank all of our faculty here today Dr. Menefee, Dr. Glacier, Dr. Matthews for this excellent webinar. For everyone in our audience be sure to register for our upcoming webinar on January 31st on the management of difficult urethral diverticula. Please follow AUGS on Twitter and Instagram or check our website for information on all upcoming webinars. So thank you all for joining and have a great evening and happy holidays. Thanks great job. Thank you. Bye. Okay thanks so much guys. Good job Sarah. It was fun. Thanks Cheryl and Sean. I learned from you guys. Appreciate it so much. Oh god you guys are good with tips and tricks. We're old. Do you know how old we are? We're old. Oh all right. Have a good one. Have a happy holiday. Bye. Thank you everybody. Good night.

pelvic organ prolapse

perianal abscess

recurrent prolapse

sacral colpopexy

transvaginal mesh placement

sacral neuromodulation

end-stage liver disease

uterovaginal prolapse

conservative management