1. AVOIDING AND MANAGING UROGYNECOLOGIC COMPLICATIONS MICKEY KARRAM MD JOHN GEBHART MD

2. Objectives Review how best to position patients and avoid nerve injury during vaginal surgery Discuss techniques to avoid lower urinary tract injury and avoid complications of midurethral slings Discuss how to avoid complications during vaginal hysterectomy Review how best to avoid complications during prolapse repairs

3. Avoiding Nerve Injury During Vaginal surgery Appropriate positioning of patient Anatomic understanding of NERVES at RISK; including Ilioinguinal Nerve; Obturator Neurovascular Bundle; & Pudendal Nerve

5. Proper Positioning for Vaginal Surgery Buttocks should be at edge of table Slight extension and lateral rotation of thigh Avoid compression of lateral knee Type of stirrups

11. CURRENTLY AVAILABLE SYNTHETIC SLINGS RETROPUBIC; below to above vs above to below PREPUBIC TRANSOBTURATOR; outside in vs inside out MINI-SLING; urogenital diaphragm vs obturator internus HOMEMADE SYNTHETIC SLINGS

13. Synthetic Sling Placement Use of Hydrodistention Plane of Dissection between Posterior Urethra and Anterior Vaginal Wall Incision should be of sufficient size Utilize catheter guide for retropubic slings Utilize anatomic landmarks

21. Ischiopubic Ramus Ischium Pubic symphysis Ilium Obturator Foramen Obturator Canal

23. Transobturator Landmarks Obturator canal Urethra SAFE ENTRY ZONE of NEEDLE Adductor longus

26. Monarc

27. TVT SECUR in Bladder

28. Reiffenstuhl,Platzer & Knapstein Mesh Position TVT

30. Minimize Risk of Bladder Entry During TVH

34. NO!

36. Vag Hyst; Elongated Cx

37. GOAL OF RECONSTRUCTIVE PELVIC SURGERY 1. Restore Anatomy Correction vs. Overcorrection 2. Restore Or Maintain Functional Or Visceral Dysfuntion 3. Restore Or Maintain Sexual Dysfunction

38. Specific Surgical Goals; Maintain or Create a Well Supported Functional Vagina What is normal vaginal length? What is normal vaginal caliber? What is normal relationship between perineum? and posterior vaginal wall? What is normal vaginal axis? What is the most important aspect of your repair? How do you determine who needs an augmented repair?

40. Anterior and Posterior Vaginal Wall Prolapse Extent of Dissection for Cystocele Repair (lateral to inferior pubic ramus and dissection of bladder base off of vaginal cuff) Extent of Dissection for Rectocele Repair (lateral to rectal gutter and proximally to preperitoneal space of cul-de-sac)

41. Appropriate use of Levatorplasty;Tight Vaginal Repairs & Perineoplasty Decrease size of vaginal caliber without creating vaginal ridge Manage elderly, sexually inactive women with tight repair or obliterative procedure Appreciate perpendicular relationship that should exist between posterior vaginal wall and perineum

42. Mesh Erosions after Vaginal Surgery Use of mesh, especially polypropylene, in placement of synthetic slings and the transvaginal repair of anterior and posterior vaginal wall prolapse results in vaginal erosion, with variably associated bleeding, drainage and dyspareunia, in 5% to 17% of cases.

43. Surgical Tips to Avoid Mesh Erosions Appropriate plane of dissection in vaginal wall Separate anterior arm passage in trocar based mesh repairs Lay mesh flat Trim mesh to fit patients anatomy

45. Posterior repair with graft augmentation

46. Jacq… Allen/ Mesh Erosion

47. Mesh Erosion/ Vault suspension

48. CONCLUSIONS Pay attention to details Have a clear understanding of anatomic landmarks of importance INDIVIDUALIZE YOUR SURGERY TO YOUR PATIENT