Catherine Matthews, Andre Player, and Tatyana Katanzarayt. So first, please join me in welcoming them, and we'll let Karen kick off our Thieves Market. Thank you, Felicia. This is going to be, I think, a really fantastic session. I'm glad that Felicia brought this up. And the idea of Thieves Market is, again, as she mentioned yesterday, sort of stealing the wisdom of our distinguished panel. And I'm really excited to be moderating it and not sitting down next to these distinguished people, but being able to get to stand up here. We'll have some time for some questions after, and we'll be also taking some questions from the audience as we go on, so as we change the speakers out. So we'll go ahead and get started. Our first speaker will be Lauren Barnes from the University of New Mexico. And this, let's see. We advance the slides. It's going back. Sorry. OK. There we go. Thank you. Your slides are up. So the mesh, the gift that keeps on giving. So thank you for presenting. Wonderful. How do I scroll through? So this is actually forward, and that's backwards. OK. Thank you so much. Thanks for having us. We have no disclosures. Our patient is a 50-year-old G2P2 who complains of vaginal bulge, voiding dysfunction, and recurrent urinary tract infections. Her surgical history is complicated. She had two surgeries in childhood for VU reflux, and it was complicated by some type of renal damage, and she thinks her left kidney was removed. She had a prolapse repair with a TVH 15 years ago, and a repeat repair the following year with mesh for recurrent prolapse and urinary retention. None of these records could be obtained. Partial mesh was removed for urinary retention and UTIs three years later after that second repair. So her pelvic exam was notable for stage 2 prolapse with a predominant posterior compartment. She had 1 centimeter of vaginal mesh that was eroded at the UVJ, and she had palpable mesh from the bladder base extending toward the ischial spines. Her PBR at that time was 120. So her goals in all of this is that she wants her prolapse repaired. She wants improved voiding dysfunction. Secondarily, she wanted her pelvic pain improved and to have fewer UTIs. She was actually not aware that she had exposed mesh. So my question is, how would you approach the differential diagnosis and the treatment plan? So my guess, my differential diagnosis is that her PBR was 120. So I think it's always difficult. The PBR that's somewhere between 100 and 200. Is that non-physiologic? Is that fine? She's having recurrent UTIs. She's already had some sort of, I'd say, a mesh complication. So you didn't give us a urinalysis, but I certainly, first thing, would want to know, does she have any mesh in her bladder or her urethra that is contributing to her recurrent UTIs? So I guess that would be part of my differential. She has a slightly shortened vagina, and she has a posterior wallop plus 1. But in general, I'd be somewhat surprised that this POPQ would be causing symptoms for pelvic organ prolapse. So I would probably want to really talk to her more like what's really bothering her in the combination of a bulge or pain in terms of any sort of a repair for that. So I guess, you know, the retention piece, I'm not sure that a PBR where I think about she already has this sling that's eroded, it appears. And so the question, again, is there a mesh in her bladder or urethra would be something I'd be concerned about? Yeah, I mean, I'd still like to clarify whether she's got a kidney or not. I mean, I think that's really important. So I'd get a CT urogram on her and a cystoscopy, I think, before I make any more decisions on where to go. Dr. Korten, any... Yeah, I'd listen the minimum. And the fact that she has a palpable mesh that extends towards the atrial spines makes me think that perhaps she had an anterior access to the sacrospinous ligament mesh placed that way. So this erosion at the vesicle urethral junction seems to probably be from that procedure and not from the previous midurethral sling, right, which was excised already. So yeah, I will start with... Okay. Kidney, no kidney. All right, well, perfect. So this was our workup. We did an office cystoscopy that revealed multiple areas of black material in the bladder wall. We had non-visualization of the left ureter in the office cystoscopy that we did later find it in the OR. She had a 4-centimeter diverticulum. Urodynamic testing revealed abdominal voiding, no urinary leakage, and a PVR of 120. We did do a CT urogram given the history of a potential absence of a kidney, and she was noted to have an atrophic left kidney that was 3.7 centimeters in length and a normal right kidney and collecting system. Her baseline creatinine was 1.19. So this was during the actual surgery that we performed on her later on, and you can see the multiple areas of black material in the bladder wall. It's a little shaky. So what do you think that the cystoscopy finding suggests, and would you consult urology for management? Looking at this and thinking about what her goals are to improve the prolapse to reduce the number of UTIs, what procedures would you consent her for? And would you do it as a staged procedure, or would you do it concomitantly? So looking at the cystoscopy, I mean, those black things, I suspect they could be sutures, but they don't really look like they've eroded into the urothelium. So I'm not convinced that those are the etiology of her infection. Really, it could be some endometriosis, but I'm more thinking that those, the way they're raised like that, they're probably some sutures from a previous repair. No, I wouldn't consult urology. And I still would like to understand a little bit more what's going on in her vagina. It sounds like there's an exposure in her vagina somewhere near the urethra vesicle junction, and I think that certainly you've got to evaluate that, and that would probably require surgical excision. I would agree. Those little black blebs probably look like something like maybe an ethel bond or something underneath the bladder, but it's well epithelialized over the top from what we saw. So I'm not convinced that that's related to her UTIs. I would not consult urology. I'm still a little bit going back to what are her primary symptoms and what does she expect. If she wants to be sexually active, she said she was not at this time, I believe. She has exposed mesh for coital purposes. Again, I think I'd like to know for sure what is it that she wants to resolve with the surgery. The mesh isn't really the problem. The question of do you leave it there or do you take it out and how is that going to improve her quality of life? Yeah, I would agree with that. What you do going forward depends on the patient's symptoms, right? And whether you think this recurring UTIs, if they're very frequent or due to the atrophic kidney, probably not, versus the mesh material or the tissue material in the bladder. If it's pain related to the mesh and the patient wants it excised, then you really have to think about and counsel the patient appropriately. She only has one kidney. So removing this one from the UVJ may potentially injure the other uterter. So I would be very careful in the management, very good counseling, appropriate counseling, and probably stent her before you remove any mesh from the vagina, given that it may be pretty close to the bladder, right? It may be pretty deep in the vagina. So injury to the other uterter would be my main concern, excising any mesh. But I wouldn't take it. I mean, I wouldn't do anything if you don't think it's causing the infections. Right. And it's not causing pain. Perfect. So in terms of our management, we ended up taking her to the operating room with urology consulted, both to help us find the UO. At the time during the initial cystoscopy, we could not see the left ureteral opening. And so they came in and performed the cystoscopy, evaluated the black material, placed ureteral stents. And then at that point, we went down and removed the vaginal mesh as far as we could find it. We decided that there was not any mesh actually in the bladder. And we performed a sacrospinous ligament fixation, a peroneoraphy. So the final diagnosis was apparently a left ureteral re-implantation. The black dots were the black material was thought to be residual silk suture that was placed when she was a child during one of her initial surgeries. She was also noted to have the vaginal mesh erosion. And we took out a large portion of that. And she had stage two pelvic organ prolapse that resolved after our intervention. I would ask the panel, what do you expect that the risk of failure is after this procedure, after she's had multiple suspension procedures that have failed, after all the interventions that we have done for this? And would you have removed the silk suture as a potential source of the recurrent UTIs? I think you don't know really. You don't have the operative reports. It's always difficult to know what exactly was done before. You don't really know what her prolapse was before. So I mean, she's at stage two with really the posterior wall, which is sacrospinous in and of itself without the coporaphy in general will do very, very well because of the posterior axis of the vagina to the sacrospinous ligament. So I would expect her, even though this is, I guess, her third surgery for prolapse, that she would do, well, you didn't talk about constipation or any other predisposing conditions that might impact the results. So I would think that she would have, throw out the 80% number for success. And again, no, I would have never gone for those silk stitches. I would have left them in situ. Agreed. I agree. Probably our best data on the risk of failure comes from the long-term optimal study, which over time shows a continued reduction in success, but based on multiple factors. But the chance of reoperation is still going to be really low. It's going to be less than probably 10% for someone like this. I think those sutures that are below the urethelium, I would not remove. I think we see those often after sacrocopopexes when any type of proline suture could have been placed on the vagina or even any other permanent sutures. And as long as they're not eroding into the urethelium, I don't see a good mechanism for them causing the source of infection. So I wouldn't remove them. And you're going to get into trouble, probably much more trouble than it's worth trying to go after something that's in the urethelium. Agreed. I agree with that. One question. You said urology was consulted for. Yes. What indication? What was the indication for consulting urology? We don't usually place our own stents. They usually place them in case we needed to do a larger resection of mesh that was in the bladder. At the initial evaluation, there was concern that that was actually mesh that was in there, or pledged. So they were involved just in case we needed to do that in the setting that she had a reimplanted kidney and all that atrophy. So we just wanted them involved to both take a look at it and to perform stenting if we needed it, just to see what we were into. So I assume you removed that. Her mid urethra, she had a mid urethral sling. Was that the erosion at the UVJD? I think it was actually a larger piece of mesh. It looked like something like an apogee, or one of the older generations of bladder meshes. Was she continent? She was. Thank you very much. That was really wonderful. Thank you. Who submitted a case. It was a very difficult decision to get down to these last three to four cases that we'll be going over. But many of the cases were able to be used on Fellows Day as well. And I got some feedback that those were very well received. So it's my pleasure now to invite Dr. Catherine Matthews up, who's going to give her Thieves Market case presentation. So Dr. Matthews, there you are. Thank you so much. Wake Forest has two of the final cases selected. So I suppose you could conclude that we need a lot of help with management. I think you should be up here on this side of the table. So I'm presenting. This is a patient of mine. But my resident, Katie Hines, who's going to be our fellow next year, put the work together in putting this. And she, unfortunately, is not here to present because she is having some complications of pregnancy. So these are our disclosures. So this is a case of a 38-year-old, very well-informed engineer who, one year prior, had delivered her baby with no anesthesia, following which she was unable to get out of her hospital bed. And she finally hobbled out of the hospital, thinking that this was, quote, unquote, a normal postpartum course. She eventually was diagnosed with pubic symphysial rupture. And she had this repaired by orthopedic surgery. In the course of the year, she noticed a progressively increasing bulging of her left labia that seemed to be greater when her bladder was full. And it would decompress when she emptied her bladder. She also complained of significant spraying of her urinary stream to one side. She otherwise was perfectly healthy and was very active and normal. On her examination, she had significant deviation of her external urethral meatus to the right. And it was displaced inferiorly. And upon performing a Valsalva maneuver, she had a 5 by 4 centimeter bulging mass into the left labium. And when you put some upward pressure just underneath the descending aspect of the ischiopubic ramus, it reduced the bulge. She had no evidence of any prolapse within the vagina itself. And I hope that we can play the video of her physical examination. OK. It's high. So perhaps play it one more time, just so everyone can take a good look at this anatomy. So she wasn't lying about the bulge. Turns out people generally tell us the truth. So I'd like to ask the panel, what would be your differential diagnosis? And what additional investigation would you recommend before offering her treatment for this condition? OK. Hi. So she seems to have a very well circumscribed mass on the labia majora. Doesn't seem to extend to the thigh, to the posterior compartment. So I would be thinking of a canal of noc cyst. If it only happens with Valsalva, it's less likely to be a mass, like a smooth muscle mass from the round ligament or anything like that. And given her prior obstetrical history, it makes me think of protruding organ through a defect in the synthesis pubis. But a canal of noc cyst, a indirect or direct inguinal hernia, or a hernia through the pelvic floor and the peroneal membrane, localized to that side of the labia. Given her history of her synthesis separation, I think you have to be really concerned that that's a peroneal hernia. And that's her bladder that's protruding in there. And I think I'd want to see some x-ray imaging of her synthesis to see if she's still got some significant separation. And I think an MRI would be really helpful here to confirm that that's her bladder that's herniating into that labia. Yeah, I agree. I think she has a peroneal hernia. And I would ideally get a dynamic MRI to evaluate it. But again, I agree. I think that's probably her bladder that's herniating there. So very good. You all passed. We got an MRI. And so I don't know if you, Marlene, would like to interpret the MRI images and tell us what it either refutes or confirms and how you would then approach her problem. That's amazing. It looks like she's got a peroneal hernia with a huge bladder. And it looks like there's synthesis separation still there. And yeah, that bladder shouldn't be there. So now she says, thank you. You're indeed correct that this is my bladder. And when my bladder is full, the bulge is much bigger. She's like, I could have told you that. I'm an engineer. Now, how are you going to fix it? How are you going to fix it? How are you going to fix it? So peroneal hernias can be fixed vaginally. They can be fixed abnominally. They can be fixed laparoscopically. This one's complicated. That's an understatement. Well, let me ask you this. I'm wondering why I volunteered to come up here. Charlie, can I just ask you, what do you think is broken to have resulted in this peroneal defect? Well, I think there's still got to be a gap in her synthesis there, and that she's got a bladder that's either coming over this gap on the top of her synthesis or in between her synthesis that's protruding there into that area. This might be, this would be really tough to fix probably vaginally, and I think you might need to do a combined procedure, maybe abdominally open or laparoscopic with the opportunity to go down below and enter that hernia sac and close something in that fashion. Yes, I agree. Most of the time if you see like a levator hernia that I have seen are more posterior, and so this is a little somewhat different variation of a peroneal hernia. I agree. I would go to the OR with orthopods, the orthopedic surgeons, because I think that she needs to have her synthesis repaired. Generally we don't do that, but this woman's a year out, and likelihood of that coming together on its own, it has, it's markedly diminished to basically zero at this point, especially now the bladder's coming through it. So, you know, you can do, like Charlie said, anterior, abdominal, laparoscopic. I think making a low fan and still incision and going into the spates of russias, and you may need to go from below as well, but for, to have that consented for both. Well, Catherine, you mentioned that the urethra was deviated to one side, right, which makes you think that the attachments and elevators to that side of the pubic symphysis are gone, and the fact that the hernia is so superficial makes you think that the peroneal membrane is gone too, so. You're indeed, there's the anatomist. You're indeed correct that that's exactly what the underlying problem was. So in essence, and this is how I thought about it, and this is how we approached it, that we did a small fan and still incision, and she had herniation of the bladder on the inferior aspect of the symphysis that had been plated on the top, but the inferior aspect was not plated, and they're all, all the muscles that normally, you know, the medial aspect of the puborectalis and the pubococcygeus was no longer attached on the left side, which is why when you just put a little bit of upward pressure underneath the symphysis, you could reduce the hernia. So we did this as a combined abdominal perineal approach. We fashioned a mesh that's in the shape of an apron with the central portion covering the inferior defect of the symphysis separation and the inferior mesh arm covering the area where the muscles would have otherwise attached to the pubic bone. And then from the perineal side, we attached the inferior mesh arm to the descending pubic ramus to basically fixate it at that site. Yeah. Well done. Yeah. Any other comments? Great. Thank you very much. I think we're probably only going to have time for one more case. And so we'd like to invite Dr. Player to come up to present Danger from Above, a case of anterior dyspareunia and lower urinary tract symptoms. Thank you. All right. Good morning, AUGS community, and thank you very much for this opportunity. So I'll be presenting Danger from Above, a case of anterior dyspareunia and lower urinary tract symptoms. This is our financial disclosures. So this patient is a 33-year-old female, power one, who was referred to us by a OBGYN for complaints of urinary urgency, nocturia, mixed urinary incontinence, urinary urgency, recurrent urinary tract infections, and dyspareunia in certain positions. During their workup, they had noted a retropubic cystic mass on a transvaginal ultrasound. These symptoms have been going on for about the past eight months for this patient, and she has no prior surgeries. On physical exam, she had a BMI of 30. She had an office speculum exam, and visual exam did not reveal any appreciable masses along the urethra or the anterior vaginal wall. However, on bimanual and digital exam, there was a subtle fullness appreciated on the left side of the vagina near the bladder base, and palpation of this area proved to be tender and elicited the pain that the patient had had from vaginal intercourse. And so the first question for the panelists is their differential diagnosis at this point and things they would like to do. It sure sounds like a urethral diverticulum, could be vaginal cysts, Gardner's duct cysts, but I definitely want to get an MRI imaging study because she's got a lot of symptoms that sure sound like a divertic, and the exam sounds like a divertic. How far from the hymen was this? So this was, so the palpation was about 3 centimeters, 2 to 3 centimeters from the hymen. I might throw a urethral stone in there with some sort of urethral anomaly as well. So for our workup, urinalysis showed that there were some moderate leukocytes and 30 WBCs. No significant blood was seen, urine culture was negative. Office cystoscopy showed that there was a large urethral diverticular opening at the 11 to 12 o'clock position in the distal 1 centimeter of the urethra, and this opening was at least 3 to 4 millimeters and opened into an even larger cystic mass. At this point, we went ahead and ordered the patient a MRI of the pelvis. This is our, the most representative transverse image from our MRI of the pelvis. Here's our best sagittal image of the pelvis with some of the dimensions, and on the interpretation, they had noted that the bulk of the lesion was 2.4 by 3.4 by 3.2 centimeters, that there were some internal septations within the structure, but no solid mass was seen, no internal debris or hemorrhage, and there was no abnormal enhancement. So at this point, diagnosis has kind of already been highly suspected. One of the main things that we wanted to know at this time was, what are some of the concerns about this pathology? So I think the diagnosis of urethral diverticulum, my concern is it's, you know, horseshoe-shaped and unfortunately in an anterior kind of horseshoe configuration it looked like, which is going to make it a little bit more challenging to remove, but I still think, I still think that's going to be your diagnosis, and it looks like this woman would benefit from a urethral diverticulectomy performed vaginally. I would agree. Your question then is with the amount of defection, her continent status after the surgery, and I think people have different ways that they would manage that, whether you do it staged or not. I personally would probably go ahead and put in an autologous sling at the same time, but some people would wait and see, but that's a pretty large diverticulum, it's mid-urethral, so I would sling her at the same time with a non-mesh sling. You're referring to concerns about pathology for cancer diagnosis given the findings on the MRI? Yeah, and in terms of what the possibility of the cancer in terms of if you need to go definitely surgically remove as much as possible and the amount of dissection that you end up doing. And for us, our main, as we said, the diagnosis anterior circumferential urethral diverticulum, need to proceed with caution in this area surgically. And our main question that was the part that made us present this case was what is your approach surgically for this particular urethral diverticulum? And we wanted to know thoughts on retropubic, supramietal. There's also been reports in literature of a vaginal approach with a circumferential urethral transection reconstruction and to discuss considerations for the location and size, bleeding, and as you had mentioned, injury to the external urethral sphincter. Okay. Yeah. So this, all of those have been reported as a way to approach that. This would not be a bad candidate for a supramietal dissection. I actually haven't done that, but it's been reported. I might find it a little disorienting. You can also still approach it vaginally, even though it's anterior. And again, an inverted U-shaped incision underneath the vagina in that area to help you with your reconstruction. I think Eric Rovner has reported on some series of these where you cut the catheter right when you do the cut, when you cut through the urethra, and that helps you get to the anterior urethra. But you can also, I mean, the opening was at 11 to 12 o'clock. I think you could still approach that vaginally. You can mobilize the urethra and get around it. It's not all that proximal, especially the opening and everything. Overall, I think that this is still best approached vaginally. The retropubic approach can be really difficult for these, and exposure can be really difficult. And especially with as low down as this is, I think it would be harder to approach retropubically than vaginally, and I would not go that route for this. And I tried not to do the urethral transsection, but if you had to, that's what you may have to do. I would agree completely. I would stay out retropubic. You think it's going to be there, but it is going to be very low. It's going to be very difficult. Retropubic, I guess if somebody was a really, really good robotic where you could actually see down, it might be even, but it's going to be difficult to get to. I would definitely go transvaginally, and I would not transect unless absolutely had to. I agree with Alan. Transsection would be the last resort, and I think you can remove most of it vaginally. Even if you remove an entire diverticulum, even if it wasn't circumferential, the rate of recurrence is relatively high, right? So unless you had a cancer diagnosis, I wouldn't transect the urethra, retropubically either because this seems to be below the retropubic urethral area. Vaginally would be my, and supramedial if you felt comfortable with that, I wouldn't. Yes, for us, our plan is to go supramedial and just do a very careful dissection in this area, obviously with issues of getting into bleeding and then compromise of the external urethral sphincter. I agree. Thank you. Thank you. Thank you. Thank you. You're going to suck our brains a little bit more? We have time for our last one. And as Dr. Catazarite is coming up, we did get one question from the audience for the panel. We wanted to give them a chance to ask you guys some questions. And so the question for the panel is the name of our karaoke team tonight for the Auxum event is the Sphincter Tones. What song would you guys recommend that we choose? Sphincter Tones. Dr. Fenner, this is coming to you. Oh, my God. Anything come to you? I'm going to have to think a minute. You're more than welcome to. Dr. Kort and Dr. Nagan, nothing? I don't know what comes to mind. Can I phone a friend? Could be Aretha Franklin's Integrity, maybe Snoop Dogg, Drop It Like It's Hot. I don't know. I don't know. I'm trying to think of a song with gas in it or something. I know. I'm like, don't put something on me, but I'm not sure what I would say. Okay, we're going to go to our last case, Management of Prolapse with Uterine Didelphys. Thank you. Hi there. I'll be presenting a case from Kaiser San Diego. And I'll try to go a little bit quickly through the history slides because I know we're short on time. This is more of a management dilemma rather than a diagnostic dilemma, so I'll kind of give you the diagnostic piece. We have no disclosures. So this is a case of a 65-year-old presenting with bothersome pelvic organ prolapse, declining pestery, desiring surgical management, sexually active, most bothered by prolapse when she was having intercourse, no other pelvic floor disorder-type complaints or recurrent UTIs. She had a past medical history of known uterine didelphys and a longitudinal vaginal septum, as well as hyperlipidemia, osteoarthritis, and obesity. She had a cesarean section bilateral tubal ligation, no other surgical history, and was a para 2, negative family and social history. Her POP-Q exam was as shown. We were unable, actually, in the office to appreciate either cervix on exam. She did have a longitudinal vaginal septum with a functional vagina on the patient's right, negative cough stress test with a relatively empty bladder, normal post-void residual. So her MRI showed two uterine horns, which were splayed apart, two cervices. Ovaries were unremarkable. Bladder was unremarkable, but they noted a low posterior ureteral insertion bilaterally. And then adjacent to the posterior urethra, benign appearing cystic lesion measuring 2 by 2 by 2.5 centimeters, extending anterior to the urethra, suggestive of a diverticulum. Kidneys were unremarkable, and the ureters were not duplicated or anything like that. This is the sagittal view of this possible diverticulum that they're seeing. So the first question is, what would be your approach to surgical management in this patient, or what would be your plan going into surgery? I'm a little confused. One thing, you said your POPQ.C was plus 6? Plus 6. But you couldn't see her cervix in the office? So I'm having a little trouble with that. That is an excellent point. So her BA was plus 6. Her cervix, it was hard to distinguish the cervix from kind of the top of the vagina, I guess I should say. Okay. So is your question what the surgical approach to the diverticulum is or to the prolapse? So for the prolapse, given that she has two services, I'll be a little reluctant to do it vaginally because I don't know if that increases the risk of ureteral injury if you have two services. We've done a couple of these in the last two years, and we've done them robotically. And then once you have the vaginal, the upper vagina completely open, then you can transect the septum, the longitudinal septum with a ligature device and make sure that you don't, that the ligature doesn't get too close to the vaginal wall so that we don't damage the vagina. And that has worked well for that indication. And then you can proceed with the prolapse repair whichever way you want. And then the diverticulum, I guess, would be similar to what we talked about before. So what's prolapsing at plus 6, do you think? I'm still, I'm sorry. I think it was unclear, honestly, and it was different from what we found intraoperatively. So I can go to our examiner anesthesia if that would help. Yeah. So I think I would do an EUA, talk to her. Because, and also, the prolapse only bothered her really with intercourse or? Mostly. Mostly. It was when she had the most bother. I think I would do an EUA to try to understand, is that the divertic that's prolapsing? And you couldn't see her cervix? I'd take her to the OR just to examine her. Agree. Okay. So we actually made a plan, given that we felt it was apical prolapse of some kind. We scheduled her for a robotic assisted laparoscopic, well, supracervical hysterectomies of both uteri. Robotic assisted laparoscopic sarcoplexy, salpingectomy, possible anterior-posterior repair, possible peroneoraphy, cysto. And then discussed possible urethral diverticulectomy, but she was asymptomatic with not having recurrent UTIs. So she elected for expectant management of that, but we did want to investigate it further on cystoscopy. So, interoperatively, here's what we found on exam under anesthesia. She had a longitudinal vaginal septum traversing essentially the full vaginal length from the apex to the hymen. She had very small cervices, which were visible on either side, but it was very difficult, even under anesthesia, to appreciate her cervices. On bimanual exam, we couldn't really appreciate her uterine sizes. We really couldn't distinguish what was uterus, what was ovary. They felt very, very small. And the right side of her vaginal septum, the vagina on that side, was definitely larger than the left side. The distal-most portion of the prolapse, we actually had our anesthesiology colleagues provide or simulate Valsalva for us, so that's the middle image here. And the distal-most portion of her prolapse actually appeared to be the region of her vaginal septum that joined with her anterior vaginal wall. So it was the septum and the anterior vaginal wall that were creating her prolapse, really not the apex in this case. So that was different from what we expected going in, but we knew that our surgical plan may change. Then, also cystoscopy, we saw normal bladder urothelium, brisk bilaterally re-relief flux, and then this very odd finding at the distal-most portion of the urethra where there was an anterior opening into either a diverticulum, and we're still not sure, or an outpouching of this left vagina as a congenital sort of situation toward her anterior labia where urine may be collecting. So it was a very odd, very odd finding. But again, we left that alone. So intraoperatively on laparoscopy, we saw very, very tiny uteri splayed out to the sidewalls bilaterally, and then these pencil-like cervices descending into the pelvis. The prolapse seemed to be coming from this. I wish I could point. Am I able to point? Yeah. So this was kind of the area that we had seen prolapsing down. The bladder was wrapped all the way posteriorly around the vagina almost like a posthysterectomy situation. And otherwise, her ovaries, her fallopian tubes were unremarkable, normal upper abdominal survey and no adhesions. Again, this is findings on the left pelvis, right pelvis. And this is a short video just showing a survey back and forth. It's only a few seconds. Hopefully we can play it. So you can see kind of where the bladder and rectum and the overlying peritoneum are joined there. And you can appreciate the adnexal structures on the right, if I can point, and on the left, same sorts of images that we just saw. So the question now is, what would you do given this finding? Kind of unusual. I don't see an indication for a robotic supracervical hysterectomy copepaxi here. I don't think you're going to do much abdominally from what I'm seeing. This still seems to be largely a vaginal prolapse. My concern is, is that still her bladder behind that bulge? And I think I'd certainly want to clarify that before trying to resect that septum and getting into bladder. I agree. So did you look back then at your MRI images a little differently perhaps at this point to see, I mean, like to try and help you? Because clearly this is not a – her uterine horns were fine. So I'm with Charlie. I mean, I would certainly want to know what was in that. And on your cystoscopy, you say you couldn't really tell? In terms of the diverticulum versus some sort of vaginal anomaly? Or the ability to be systo-ing and examining vaginally at the same time and palpation and to be able to see what was in the bulge? That we didn't do. But it did look very similar to a classic anterior wall prolapse, even if you didn't know there was a septum there. It looked like that anterior wall. When you filled the bladder, did you see a bigger bulge? Good question. Okay. I think so. Let's say yes. She had two kidneys and the urethra was opening at the normal position. She didn't have hypospadias or anything like that. Correct. Okay. I'll just tell you what we did. Good. So we actually did proceed with a thicker colpopexy, almost in the technique of a post-hysterectomy thicker colpopexy. So we did an anterior vaginal dissection. What did you colpo? Mesh attachment to the vagina, which was under the bulge. We basically divided the peritoneum between the bladder and rectum, dissected it off, attached mesh. You cut that septum? We did not do anything to the septum, as that was actually not bothering her. She had a functional vagina on the right side. And that was part of the consideration of not approaching this vaginally because the septum would have needed to be dealt with in that case. So we left the septum alone, left the diverticulum or vaginal anomaly alone. Was the hysterectomy done? We did not perform hysterectomies. We left both uteri and situ, attached the sacral tail in the usual fashion, normal sacral dissection. This is our result afterwards. And then immediate postoperative result was this. And hopefully that holds up well. So that bulge is vaginal wall? Mm-hmm. Did you do Y-mesh or just an anterior mesh? We did a very small Y-mesh, but it was really just focusing on what we were kind of making the new apex, the presumed dependent portion of the prolapse. Isn't your assumption that there's no uterus sacral? The uterus sacrals are on the surface of that, and how about if there was no support? Can you repeat the question? Yes. So the question was, given that the uteri were on the sides, would there not be then any uterus sacrals holding up that portion of the vagina? And exactly. So we were basically just simulating the apical. Essentially an interstitial sort of situation of this very unusual anatomy with the uteri way off to the side. Great. Great. Thank you very much. Applause

pelvic organ prolapse

mesh complications

CT urogram

cystoscopy

diverticulum

individualized treatment plans

labia

uterine didelphys