STUDY OBJECTIVE:Müllerian anomalies are congenital anomalies of the female reproductive tract. Patients with Müllerian anomalies frequently report difficulty with sexual function, yet no standardized patient-reported sexual function tools exist specific to this population. This study aimed to explore sexual function, through qualitative interviews, in women with Müllerian anomalies to identify themes and develop a conceptual model to later be used in the development of a sexual function questionnaire. METHODS:We conducted semi-structured qualitative interviews with 11 female patients with Müllerian anomalies. The interview guide was developed based on expert consultation and extensive literature review to identify what current sexual function questionnaires address and what sexual function concerns related to Müllerian anomalies are reported. Questions explored topics such as sexual pleasure, interpersonal relationships, physical and emotional discomfort during sex, sex education received from healthcare providers, and treatment goals related to sexual function. Interviews were conducted with female-identifying patients with Müllerian anomalies over 4 months. Interviews were transcribed, and qualitative thematic analysis was performed in NVivo to identify themes. RESULTS:Eleven participants were recruited with Müllerian anomalies affecting the uterus, cervix, and/or vagina. Six major themes affecting sexual function were identified from interview transcripts: symptoms, diagnosis, providers, treatment, self-concept, and social context. Major and minor themes were used to develop a conceptual model. CONCLUSION:Women with Müllerian anomalies face unique sexual challenges due to their anatomy and socio-emotional interplay, in addition to those experienced by the general population. Patient education materials and screening tools specific to this population are needed.

Introduction and HypothesisThe objectives of this video are to provide an overview of autologous grafts, flaps, and biologic grafts for use in vaginal lengthening procedures and to discuss management of shortened vaginal length with differing approaches.MethodsThis video reviews iatrogenic and medical causes of shortened vaginal length and management through conservative and surgical approaches. We discuss vaginal dilation-only protocols. We also describe surgical management with buccal grafts, split-thickness grafts, pudendal thigh flaps, and biologic grafts. The first case presents a patient with graft-versus-host disease who was managed via lysis of vaginal adhesions. The second case presents an iatrogenic shortened vaginal length with use of a split-thickness graft via a vaginal surgical approach. The third case presents a patient with a complex genitourinary sinus with upper vaginal obliteration who was managed via a robotics-assisted approach with a biologic graft for vaginal lengthening.ConclusionsCommon causes of shortened vaginal length are iatrogenic and medical etiologies that urogynecologists will see. As vaginal and minimally invasive surgeons, urogynecologists may consider acquiring grafting techniques or collaborative patient care to offer vaginal lengthening procedures to their patients.

Exosomes, an acellular regenerative biologic, have demonstrated success in resolving vaginal mesh exposures after pelvic reconstructive surgery; little data exists for their use for prevention of mesh-based complications. This study evaluated the early efficacy of purified exosome product (PEP) for preventing mesh exposures. Ten Yorkshire-crossed pigs underwent mesh sacrocolpopexy with two high-risk-for-exposure configurations: mesh fold ventrally, vaginotomy dorsally. PEP in hyaluronic acid (HA) or HA-only (control) was injected at baseline. Twelve weeks later, animals were euthanized and evaluated for mesh exposure and histologic changes. None of the PEP-treated tissues demonstrated mesh exposure (0/6); all control group animals experienced a mesh exposure (4/4 mesh fold configuration, 2/4 vaginotomy configuration). Control tissues exhibited higher fibrosis (vaginotomy fibrosis score: median(IQR); 3(3,3) control, 2(1,2) PEP; p = 0.03) and greater epithelial apoptosis (mesh fold TUNEL+area fraction: median 18.9 control vs 0.43 PEP; p = 0.02). Our study demonstrated that PEP treatment mitigated the risk of early mesh exposure.

The goal of this work is to review the most common techniques for surgical vaginoplasty. Specifically, this review delves into the history of surgical approaches to vaginal agenesis, including the landmark studies that first described the approaches we still use today. Next, we describe each of the three most commonly used techniques – the McIndoe, the Vecchietti, and the Davydov – including a review of the major case series published on each technique, and supplemented by medical illustrations. Lastly, we outline the most exciting innovations in the treatment of vaginal agenesis. The field of vaginal reconstruction is experiencing exciting new growth in the realms of increasingly minimally invasive approaches, tissue engineering, and new graft materials or strategies for neovaginal creation. Throughout history, there have been numerous approaches to the clinical conundrum of vaginal agenesis. There are pros and cons to each of the three most commonly used techniques. Lastly, innovations in the realm of bioengineering are advancing this field and creating exciting new possibilities for the care of these patients.

Pelvic organ prolapse (POP) is a morbid and costly condition that affects millions of women worldwide. Given the shortcommings of the current treatments, novel preventative and therapeutic approaches are needed. This manuscript is part of the International Urogynaecologogy Consultation (IUC) on pelvic organ prolapse (POP) chapter four on new and novel treatments for pelvic organ prolapse. The current expert narrative review (1) highlights the rationale for novel treatments for POP; (2) summarizes the exisitng mechanistic insights into physiologic alterations needed to inform the development of novel preventative and therapeutic strategies for POP; (3) reviews relevant modern tools that can help establish causal relationships between epidemiologic risk factors and POP pathogenesis; (4) describes prevention-focused interventions and advancements in treatment-focused interventions to date; and (4) emphasizes requirements for responsible translation of discoveries into novel treatments and safe incorporation of new treatments into clinical practice. Importantly, the review underscores the need for multidisciplinary adequately funded research and training programs as an absolute prerequisite for enabling a long overdue shift in clinical paradigm-instead of relying on delayed compensatory "one-size-fits-all" treatments that do not address the underlying pathophysiology, the focus should be on preventing or mitigating POP through personalized medicine approaches supported by team science.

(Abstracted from Urogynecology 2024;30:658–664) Discussions surrounding surgical approach and minimizing complications and perioperative risks are necessary for many surgeries. Obesity introduces additional variables and risks that need to be discussed in making decisions about pelvic reconstructive surgery, particularly because it is associated with comorbidities such as diabetes, cardiovascular disease, chronic kidney disease, and others.

Importance Obesity adds complexity to the decision of surgical approach for pelvic organ prolapse; data regarding perioperative complications are needed. Objective The aim of the study was to evaluate associations of body mass index (BMI) and surgical approach (vaginal vs laparoscopic) on perioperative complications. Study Design Patients who underwent prolapse surgery were identified via the Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database 2007–2018. Thirty-day major complications were compared across BMI to identify an inflection point, to create a dichotomous BMI variable. Multivariable logistic regression was used to assess the association between BMI and complications. An interaction term was introduced to evaluate for effect modification by operative approach. Results A total of 26,940 patients were identified (25,933 BMI < 40, 1,007 BMI ≥ 40). The proportion of patients experiencing a major complication was higher in the BMI ≥ 40 group (2.0 vs 1.1%, P = 0.007). In multivariate analysis, the odds of a major complication was 1.8 times higher for women with a BMI ≥ 40 (95% confidence interval, 1.1–2.9, P = 0.04). There was a significant interaction between operative approach and BMI; therefore, further analyses were restricted to either vaginal or laparoscopic operative approaches. Among women who underwent vaginal prolapse repair, there was no difference in the odds of a major complication (adjusted odds ratio, 1.4; 0.8–2.4; P = 0.06). Among women who underwent laparoscopic repair, those with a BMI ≥ 40 were 6 times more likely to have a major complication (adjusted odds ratio, 6.0; 2.5–14.6; P < 0.001). Conclusions Body mass index ≥ 40 was associated with an increased odds of a 30-day major complication. This association was greatest in women who underwent a laparoscopic prolapse repair.

STUDY OBJECTIVE:To provide a brief overview of noncongenital causes of vaginal obliteration and stenosis, discuss a unique case of vaginal agglutination in a patient who developed genital graft-versus-host disease (GVHD) after receiving a bone marrow transplant (BMT), and present the steps of a laparoscopic total hysterectomy and lysis of vaginal adhesions that successfully restored vaginal patency without the need for grafting. DESIGN:This video gives an overview of noncongenital causes of vaginal obliteration with a focus on genital GVHD. SETTING:GVHD is a known possible complication of BMT. This condition can lead to vaginal obliteration, affecting sexual performance and quality of life. INTERVENTIONS:We discuss the clinical course of a 54-year-old female with history of acute monocytic leukemia treated with chemotherapy and a BMT. She subsequently developed genital GVHD with complete vaginal obliteration, precluding penetrative intercourse and causing pain, discomfort, and decreased quality of life. We present a combined laparoscopic and vaginal surgical procedure that allowed for the creation of a neovagina with a normal length and caliber. While grafting is sometimes necessary due to inflammation and scarring, we were able to avoid a graft by using a combined laparoscopic and vaginal approach, followed by restoration of continuity between the unaffected upper and lower vaginal tissues. CONCLUSION:GVHD can be quite debilitating for patients. A combined surgical approach is a feasible option for patients with complex pathology not amenable to simple transvaginal adhesiolysis. Surgical restoration of the vagina does not necessarily require the use of a graft if the anatomy is reestablished successfully. VIDEO ABSTRACT.

Women's health research is woefully underfunded. A 2021 study found that in disease states that unequally affect one gender, a disproportionate amount of funding from the National Institutes of Health (NIH) went to male-dominated areas. The authors found that in approximately 75% of cases, the funding was provided to male-dominated diseases.1 In addition to the disproportionately smaller amount of NIH research funding that is allocated to women's health, the majority goes to research involving reproductive-aged women and is often allocated specifically to pregnancy and maternity issues.2 The Office of Research of Women's Health noted that of the proportion of the overall NIH research spending by disease, condition, and special initiative from fiscal year 2017 to 2019, only 10% was allocated to women's health research; however, in that same year, the proportion of that money spent on contraception and pregnancy was 78.6% of the total, despite the fact that women spend the minority of their lives bearing children.2 Women's health care should encompass the full life span of women, including conditions affecting postreproductive and geriatric women, the fastest-growing segment of the U.S. population. Pelvic floor disorders (PFDs) are common conditions that can significantly affect a woman's quality of life. Approximately 25% of women experience at least 1 PFD, and this percentage is likely higher in women older than 65 years, as it is well established that all PFDs increase after menopause.3,4 PURPOSE The American Urogynecologic Society (AUGS) recognizes the importance of evaluating the conditions women face throughout their lives, including conditions that become more prevalent in the postreproductive years. Furthermore, the mission of AUGS is to drive excellence in comprehensive care for women with PFDs. Aligning the mission of AUGS with the need to increase the amount of research funding directed toward women's health beyond maternity and reproductive care identified an opportunity to develop a National Urogynecology Research Agenda focused on research funding for PFDs. At the direction of the AUGS Board of Directors, the AUGS Scientific Committee was charged with the task of creating a Research Agenda that would serve the urogynecology research community by synthesizing and presenting key gaps and research priorities for a variety of PFDs. Six conditions were prioritized for inclusion in the Research Agenda, including pelvic organ prolapse (POP), lower urinary tract symptoms, recurrent urinary tract infections (rUTIs), bladder pain syndrome/interstitial cystitis (BPS/IC) and myofascial pelvic pain (MFPP), female sexual health, and fecal incontinence (FI). Once the working group generated a manuscript and the internal revisions were complete, the Research Agenda was reviewed and edited by 9 external reviewers and then subsequently by the AUGS Publications Committee and the AUGS Board of Directors. Edits were considered, and revisions made accordingly to create the final Research Agenda (https://www.augs.org/research-agenda/). RESULTS The following is a summary of the 6 topics of interest identified for the National Urogynecology Research Agenda. Lower Urinary Tract Symptoms/Urinary Incontinence Stress urinary incontinence (SUI) affects 14%–41% of biologic female patients between the ages of 30 and 60 years.5,6 Overactive bladder in women has been estimated to affect millions with its greatest prevalence (>50%) in adults 60 years or older.7 Numerous studies have demonstrated the negative impact of overactive bladder and SUI on independence, self-esteem, mental health conditions, and interpersonal relationships.8–11 Voiding dysfunction is described using a variety of symptoms that depart from normal voiding sensation and function.7 A large international survey study of a cohort of women older than 40 years reported 5.2% experienced voiding symptoms and 14.9% experienced coexisting voiding and storage symptoms.12,13 The etiologies of voiding dysfunction in women are not well understood. Further, the understanding of the impact of voiding dysfunction on quality of life is limited in part due to the historic lack of validated questionnaires for female voiding dysfunction. The following categories were identified as outstanding knowledge gaps for conditions of lower urinary tract symptoms: clinical phenotyping; combined therapies; voiding dysfunction; health disparities; central nervous system control mechanisms, neuromodulation, and electrostimulation outcomes; biomaterials for SUI treatment; impact of pregnancy/childbirth on lower urinary tract symptoms management; and the impact of anticholinergic medications on cognition. Pelvic Organ Prolapse Pelvic organ prolapse is the descent of 1 or more of the anterior, posterior, or apical pelvic floor compartments, which affects up to 50% of all women.14 This condition can severely affect quality of life, prompting 1 in 7 women in the United States to undergo surgical correction of POP.15,16 Worsening POP has also been associated with deteriorating physical function, anxiety, depression, fatigue, sleep disturbance, and lower satisfaction with participation in social roles.17 Overall, the pathophysiologic mechanisms underlying the development, progression, and severity of POP are inadequately understood. No effective preventive strategies exist against POP, and current treatment modalities are delayed and compensatory. Identified themes within POP that require further exploration in well-designed studies are the following: normal and abnormal functional anatomy and biomechanics; molecular, cellular, genetic, and biomechanical factors; therapies for prevention; treatment, treatment failure and recurrence; health disparities; and societal impact and financial burden of treatment modalities. Fecal Incontinence Fecal incontinence, or accidental bowel leakage, defined as unintentional leakage of mucous, liquid, or solid stool, is a prevalent condition, affecting up to 24% of women.18 Fecal incontinence has a profound negative impact on women's quality of life, as well as a substantial economic burden both at the individual and health care system levels. As a result of the associated stigma, women with FI often suffer in silence. As the prevalence increases with age, paralleling the rapidly growing aging population, the impact of FI on society will continue to expand. Research gaps were identified, and recommendations were provided for the following categories: pathogenesis; classifications of FI types; treatments and prevention; reporting/validated measures; psychosocial consequences and providing support; and research inclusion/diversity. Recurrent UTIs Urinary tract infections are some of the most common bacterial and fungal infections, and they disproportionately affect women. More than one half of women have 1 UTI in their lifetimes, and approximately one third develop rUTI. Women suffering from rUTIs experience burdens related to symptoms and treatment, including adverse effects from antibiotics and risks posed by multidrug- and azole-resistant bacteria. Despite the substantial impact of rUTI, there is a paucity of evidence upon which to base accurate diagnosis, treatment, and prevention. The rUTI working group identified the following research categories: characterization of host-microbial interaction in the female bladder and with neighboring microbial niches, biomarker rapid detection, and patient-centered outcomes and care equity. Recommendations around these categories generally focused on large, multicenter, socioeconomically diverse studies that explore patient-centered outcomes and the impact of rUTI in diverse communities. Sexual Health in Women With PFDs Patients with PFD have a high prevalence of sexual dysfunction, and lack of improvement in sexual function after pelvic reconstructive surgery is viewed by patients as a serious complication. Patients may be embarrassed by urine loss during sexual activity and how their genitalia appear and/or express concerns that their prolapse may prohibit sexual activity.19,20 The societal and economic burden of sexual dysfunction in women with PFDs is high. A more thorough understanding of the prevalence of sexual dysfunction among each of the individual PFDs is essential. There is an urgent need to raise awareness of the importance of sexual function in women with PFDs and to investigate treatments and solutions rather than simply defining the conditions.21,22 Knowledge gaps included the need to improve overall understanding of basic anatomy and physiology and how they relate to sexual function; standardization in terminology, screening, and reporting; patient-centered counseling and changes with PFD surgery on sexual function; and explore sexual health and dysfunction in understudied populations with PFDs. Bladder Pain Syndrome/Interstitial Cystitis and Myofascial Pelvic Pain Bladder pain syndrome/interstitial cystitis and MFPP are 2 chronic pain conditions that are commonly assessed and treated by urogynecologists. Bladder pain syndrome/interstitial cystitis is characterized by bladder pain with associated urinary urgency, frequency, and nocturia lasting greater than 6 weeks in the absence of other identifiable causes.23 Bladder pain syndrome/interstitial cystitis symptoms are common; yet, the condition is often underdiagnosed with a lack of understanding the disease pathogenesis. The etiology of BPS/IC is multifactorial with interactions between autoimmune, neuroendocrine, allergic, and infectious pathways.24,25 Myofascial pelvic pain can be acute; however, the chronic syndrome is characterized by pain originating from the pelvic floor muscles.26 Myofascial pelvic pain is persistent or episodic and occurs in the absence of a local pathological condition with symptoms suggestive of lower urinary tract, sexual, bowel, or gynecological dysfunction.27–31 The etiology of MFPP is also not well understood and is likely multifactorial. Several theories have been suggested, including metabolic imbalance at the motor end plate in peripheral tissue, central sensitization of pain, and neuromuscular microtrauma.32–35 For BPS/IC, 4 categories were identified: diagnosis, disease phenotypes, current treatments, and treatments on the horizon. For MFPP, the following categories were included: prevalence, etiology, diagnosis, and treatment. For each of these categories, knowledge gaps/research priorities were elaborated on with recommendations given for each in the final Research Agenda. CONCLUSION There are extensive areas to be explored in women's health research, especially for conditions women face throughout their lives, including conditions such as PFDs that become more prevalent in the postreproductive years. The main goal of the Research Agenda is to synthesize and present key gaps and research priorities for a variety of PFDs. There is a clear need to increase funding to investigate these crucial topics. The intention is that this agenda will serve as a living document to be updated as knowledge advances and research priorities evolve. This document will also help to guide researchers when putting forth funding applications and should be used by PFD advocates when championing research dollars that can be directed toward women's health care beyond reproduction.

From the Division of Urogynecology, Department of Ob/Gyn, Duke Hospital, Durham, NC. Correspondence: Cassandra Kisby, MD, MS, FACOG. E-mail: [email protected]. The product was donated by Rion, LLC, for research, shared pending patent for 3D-printed vaginal molds (shared with John Gebhart, MD).

The objectives of this video are to provide a brief overview of Müllerian agenesis, discuss a case of partial vaginal agenesis with a functional uterus, and present the steps of a staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification. We give an overview of Mayer–Rokitansky–Küster–Hauser syndrome, and review its incidence, clinical presentation, diagnostic evaluation, and treatment options. We present the case of a 23-year-old woman with partial vaginal agenesis, and her clinical course through conservative management with hormonal suppression and dilator therapy leading up to urogynecological surgical treatment. We describe a staged surgical approach that highlights the value of cystoscopy and laparoscopy to better delineate our patient’s anatomical variations. Additionally, a mini-laparotomy and placement of an intrauterine Malecot catheter allowed for the drainage of prominent hematometra, relief of menstrual outflow obstruction, and epithelialization of a tract between the uterus and the planned neovaginal space. Ultimately, a neovagina was created using a staged McIndoe technique, leading to utero-neovaginal unification and unobstructed menses. In conclusion, our approach should be considered a feasible option for anatomical restoration via the creation of a neovagina in patients with Müllerian anomalies, even in the presence of a functional uterus.

Importance Diabetes is an independent risk factor for urinary incontinence, and its impact on rates of postoperative incontinence after pelvic reconstructive surgery remains unexplored. Objective The aim of the study was to compare the incidence of postoperative stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence in patients with diabetes mellitus undergoing surgery for pelvic organ prolapse (POP) with or without SUI surgery. Study Design This is a secondary analysis of a multicenter retrospective cohort study involving 10 diverse medical centers that identified a cohort of women with diabetes who had prolapse and/or anti-incontinence surgery. We compared rates of postoperative urinary incontinence among patients who had surgery for prolapse and incontinence versus surgery for prolapse only. Results Three hundred five patients had surgery for prolapse and incontinence, 330 had surgery for prolapse only, and 189 had anti-incontinence surgery only. De novo UUI was higher among those who underwent surgery for POP and SUI compared with surgery for POP alone (26.4% vs 14.1%, P < 0.01). Rates of persistent SUI (21% vs 4.9%, P < 0.01) and mixed urinary incontinence (15.9% vs 2.7%, P < 0.01) were higher for those who underwent prolapse surgery alone versus prolapse and an incontinence procedure. No differences were seen in hemoglobin A 1C levels between those who did and did not report postoperative UI. Conclusions We found that postoperative de novo UUI rates were high among patients with diabetes after pelvic reconstructive surgery, with the incidence being significantly higher for those who had surgery for prolapse and incontinence compared with surgery for prolapse only.

BACKGROUND:Surgical vaginoplasty is a highly successful treatment for congenital absence of the vagina. One key to long-term success is the use of an appropriate vaginal mold in the immediate postoperative period. We present the use of a three-dimensional (3D)-printed vaginal mold, customizable to the anatomy of individual patients.TECHNIQUE:Vaginal molds were designed using a 3D modeling software program. The design included narrowing around the urethra, holes for egress of secretions, and a knob for insertion and removal. Dental resin was 3D-printed into various-sized vaginal molds, and postprocessing was performed.EXPERIENCE:We present the use of the 3D-printed mold for a patient with a history of cloacal exstrophy and a unique pelvic shape. Two prior neovagina surgeries in this patient had been unsuccessful due to ineffective handheld dilator use; the patient experienced success with the 3D-printed intravaginal mold.CONCLUSION:The use of the 3D-printed vaginal mold is an alternative to the limited commercially available models today and allows for customization to user anatomy. With 3D printers becoming more widely accessible, we believe this method could become universally accepted, with hopes of contributing to increased patient satisfaction and decreased complications.

You have accessJournal of UrologyCME1 May 2022V06-07 MANAGEMENT OF VAULT PROLAPSE INCLUDING A BOWEL OBSTRUCTION: EXPANDING THE ROLE OF TRANSVAGINAL SURGERY Elizabeth J. Olive, Cassandra K. Kisby, Scott R. Kelley, and Brian J. Linder Elizabeth J. OliveElizabeth J. Olive More articles by this author , Cassandra K. KisbyCassandra K. Kisby More articles by this author , Scott R. KelleyScott R. Kelley More articles by this author , and Brian J. LinderBrian J. Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002586.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the past, management of bowel pathology occurring within post radical cystectomy vaginal prolapse has been described via an abdominal surgical approach. This case demonstrates concomitant advanced pelvic organ prolapse and partial small bowel obstruction managed via transvaginal small bowel resection and colpocleisis. METHODS: The patient is an 82-year-old female with a history of a radical cystectomy and ileal conduit two years prior for bladder cancer, that was transferred from an outside hospital for incarcerated vaginal prolapse including a small bowel obstruction with transition point inside the prolapse. She had previously unsuccessfully tried several pessaries for her prolapse. She was widowed and not sexually active. After conservative management of her bowel obstruction was unsuccessful, she was taken to the operating room for transvaginal exploration and prolapse repair, with the understanding than an abdominal approach may be needed. Intraoperatively, with transvaginal intraperitoneal access we identified an isolated area of indurated small bowel adherent to the prolapse. Colorectal Surgery performed a transvaginal small bowel resection with stapled anastomosis and a modified colpocleisis was performed to address her prolapse. RESULTS: Her postoperative course was uncomplicated and at 6 months, she reported normal bowel function and had no evidence of prolapse recurrence. CONCLUSIONS: We present a case of bowel pathology associated with vaginal prolapse, managed with transvaginal small bowel resection and colpocleisis. This case demonstrates the feasibility of this procedure when working with a multi-disciplinary team and localized bowel pathology. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e567 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth J. Olive More articles by this author Cassandra K. Kisby More articles by this author Scott R. Kelley More articles by this author Brian J. Linder More articles by this author Expand All Advertisement PDF DownloadLoading ...

Urinary incontinence afflicts up to 40% of adult women in the United States. Stress urinary incontinence (SUI) accounts for approximately one-third of these cases, precipitating ~200,000 surgical procedures annually. Continence is maintained through the interplay of sub-urethral support and urethral sphincter coaptation, particularly during activities that increase intra-abdominal pressure. Currently, surgical correction of SUI focuses on the re-establishment of sub-urethral support. However, mesh-based repairs are associated with foreign body reactions and poor localized tissue healing, which leads to mesh exposure, prompting the pursuit of technologies that restore external urethral sphincter function and limit surgical risk. The present work utilizes a human platelet-derived CD41a and CD9 expressing extracellular vesicle product (PEP) enriched for NF-κB and PD-L1 and derived to ensure the preservation of lipid bilayer for enhanced stability and compatibility with hydrogel-based sustained delivery approaches. In vitro, the application of PEP to skeletal muscle satellite cells in vitro drove proliferation and differentiation in an NF-κB-dependent fashion, with full inhibition of impact on exposure to resveratrol. PEP biopotentiation of collagen-1 and fibrin glue hydrogel achieved sustained exosome release at 37 °C, creating an ultrastructural "bead on a string" pattern on scanning electron microscopy. Initial testing in a rodent model of latissimus dorsi injury documented activation of skeletal muscle proliferation of healing. In a porcine model of stress urinary incontinence, delivery of PEP-biopotentiated collagen-1 induced functional restoration of the external urethral sphincter. The histological evaluation found that sustained PEP release was associated with new skeletal muscle formation and polarization of local macrophages towards the regenerative M2 phenotype. The results provided herein serve as the first description of PEP-based biopotentiation of hydrogels implemented to restore skeletal muscle function and may serve as a promising approach for the nonsurgical management of SUI.

OBJECTIVE:The aim of the study was to compare vaginal wound healing after exosome injection in a porcine mesh exposure model with (1) single versus multiple dose regimens and (2) acute versus subacute exposure.METHODS:Six 80-kg Yorkshire-crossed swine each had 2 polypropylene meshes implanted to create the vaginal mesh exposure model. Animals were divided into 3 groups based on number and timing of exosome injection: (1) single purified exosome product (PEP) injection (acute-single), (2) weekly PEP injections (acute-weekly, 4 total injections), and (3) delayed single injection (subacute-single). Acute and subacute injections occurred 1 and 8 weeks after mesh implantation, respectively. EdU, a thymidine analog, was given twice weekly after the first injection to track tissue regeneration. Euthanasia and tissue analysis occurred 4 weeks after the first injection. ImageJ was used to quantify epithelial thickness, cellular proliferation, and capillary density. Statistical analysis was performed using analysis of variance and post hoc Tukey test.RESULTS:Acute-single PEP injection tissues mirrored pilot study results, validating replication of protocol. Within the acute groups, weekly dosing resulted in 1.5× higher epithelial thickness (nonsignificant), 1.8× higher epithelial proliferation (P < 0.05), and 1.5× higher regenerated capillary density (P < 0.05) compared with single injection. Regarding chronicity of the exposure, the subacute group showed 1.7× higher epithelial proliferation (nonsignificant) and similar capillary density and epithelial thickness as compared with the acute group.CONCLUSIONS:Exosome redosing resulted in significantly greater epithelial proliferation with significantly higher regenerated capillary density, leading to a trend toward thicker epithelium. Subacute exposure exhibited similar regeneration to acute exposure despite a delayed injection timeline. These results contribute to a growing body of preclinical research demonstrating utility of exosomes in pelvic floor disorders.

OBJECTIVES:Poor control of diabetes mellitus is a known predictor of perioperative and postoperative complications. No literature to date has established a hemoglobin A1c (HbA1c) cutoff for risk stratification in the urogynecology population. We sought to identify an HbA1c threshold predictive of increased risk for perioperative and postoperative complications after pelvic reconstructive surgery.METHODS:This multicenter retrospective cohort study involving 10 geographically diverse U.S. female pelvic medicine and reconstructive surgery programs identified women with diabetes who underwent prolapse and/or stress urinary incontinence surgery from September 1, 2013, to August 31, 2018. We collected information on demographics, preoperative HbA1c levels, surgery type, complications, and outcomes. Sensitivity analyses identified thresholds of complications stratified by HbA1c. Multivariate logistic regression further evaluated the association between HbA1c and complications after adjustments.RESULTS:Eight hundred seven charts were identified. In this diabetic cohort, the rate of overall complications was 44.1%, and severe complications were 14.9%. Patients with an am HbA1c value of 8% or greater (reference HbA1c, <8%) had an increased rate of both severe (27.1% vs 12.8%, P < 0.001) and overall complications (57.6% vs 41.8%, P = 0.002) that persisted after multivariate logistic regression (odds ratio, 2.618; 95% confidence interval, 1.560-4.393 and odds ratio, 1.931; 95% confidence interval, 1.264-2.949, respectively). Mesh complications occurred in 4.6% of sacrocolpopexies and 1.7% of slings. The average HbA1c in those with mesh exposures was 7.5%.CONCLUSIONS:Preoperative HbA1c of 8% or higher was associated with a 2- to 3-fold increased risk of overall and severe complications in diabetic patients undergoing pelvic reconstructive surgery that persisted after adjustments.

The objective was to demonstrate the build and use of a low-cost, moderate-fidelity simulation model for LeFort colpocleisis. We a present a video demonstrating the creation of a LeFort colpocleisis model, the mounting of this model to a pre-existing vaginal hysterectomy simulator (SimVaHT), and the use of the model to teach the steps of the LeFort colpocleisis procedure. This LeFort colpocleisis model is easy to make, from readily available materials, and is inexpensive. It can help trainees to enhance their intraoperative learning.

INTRODUCTION AND HYPOTHESIS:We reviewed a case of concomitant advanced pelvic organ prolapse and partial small bowel obstruction managed via transvaginal small bowel resection and native tissue prolapse repair.METHODS:The patient is an 82-year-old woman with a history of a radical cystectomy and ileal conduit 2 years prior for bladder cancer that was transferred from an outside hospital for incarcerated prolapse including a small bowel obstruction with transition point inside the prolapse. She had previously unsuccessfully tried several pessaries for her prolapse. She was widowed and not sexually active. After conservative management of her bowel obstruction was unsuccessful, she was taken to the operating room for transvaginal prolapse repair. Intraoperatively, we encountered an isolated area of indurated bowel adherent to the prolapse. Colorectal surgery performed a transvaginal small bowel resection with stapled anastomosis, and a modified LeFort colpocleisis was performed to address her prolapse. Her postoperative course was uncomplicated, and at 6 months, she reported normal bowel function and had no evidence of prolapse recurrence.CONCLUSION:We present a case of incidental bowel pathology during vaginal prolapse surgery, requiring a small bowel resection. This case demonstrates the feasibility of this procedure when working with a multi-disciplinary team and localized bowel pathology.

Supplemental digital content is available in the text. Objectives The purpose of this study was to explore the utility of an injectable purified exosome product derived from human apheresis blood to (1) augment surgical closure of vaginal mesh exposures, and (2) serve as a stand-alone therapy for vaginal mesh exposure. Methods Sixteen polypropylene meshes (1×1–3×3 cm) were implanted in the vaginas of 7 Yorkshire-crossed pigs by urogynecologic surgeons (day 0). On day 7, group 1 underwent surgical intervention via vaginal tissue suture reclosure with (n=2 pigs, n=4 meshes) or without (n=2 pigs, n=4 meshes) exosome injection; group 2 underwent medical intervention with an exosome injection (n=3, n=8 meshes). One animal in group 2 was given oral 2′-deoxy-5-ethynyluridine to track cellular regeneration. Euthansia occurred at 5 weeks. Results Mesh exposures treated with surgical closure alone experienced reexposure of the mesh. Exosome treatment with or without surgical closure resulted in partial to full mesh exposure resolution up to 3×3 cm. Exosome-treated tissues had significantly thicker regenerated epithelial tissue (208 μm exosomes-only and 217 μm surgery+exosomes, versus 80 μm for surgery-only; P < 0.05); evaluation of 2′-deoxy-5-ethynyluridine confirmed de novo regeneration throughout the epithelium and underlying tissues. Capillary density was significantly higher in the surgery+exosomes group (P = 0.03). Surgery-only tissues had a higher inflammatory and fibrosis response as compared with exosome-treated tissues. Conclusions In this pilot study, exosome treatment augmented healing in the setting of vaginal mesh exposure, reducing the incidence of mesh reexposure after suture closure and decreasing the area of mesh exposure through de novo tissue regeneration after exosome injection only. Further study of varied local tissue conditions and mesh configurations is warranted.