Surgical Tips from Experts: Highlights from IUGA

Surgical Tips from Experts: Highlights from IUGA

Prepared by Ipek Betul Ozcivit Erkan, MD

Þ   Prof. John B. Gebhart, MD, MS – Repairing the Constricted/Obliterated Vagina

Prof. Gebhart provided a practical overview of the management of vaginal stenosis and obliteration, emphasizing simple, reproducible approaches rather than complex congenital anomalies or rotational flaps.

A central teaching point was that “the vagina does not close on its own.” Identifying the underlying cause—atrophy, lichenoid/autoimmune disease, post-surgical adhesions, or radiation—is critical to successful treatment.

Disease control: topical estrogen for atrophy, clobetasol for lichen sclerosus, and tacrolimus for lichen planus (with attention to oral symptoms).
Surgery: complete release of constriction bands or fusion lines, with careful dissection to the side walls to avoid residual bands.
Postoperative care: mandatory vaginal dilation combined with topical therapy to maintain patency and prevent re-obliteration.

Key surgical pearls:

·       In lichen sclerosus, total vulvar fusion may occur while the vagina remains preserved; surgery should be tailored to sexual activity, balancing functional and anatomic goals.

·       Differentiate true cervical anatomy from mid- or upper-vaginal constriction rings.

·       Use clamps or forceps to measure vaginal length before incision.

·       Dissect laterally to prevent reformation; use electrocautery carefully to avoid bladder and rectal injury.

·       In lichen planus, gentle spreading and blunt dissection with Mayo scissors helps define fusion planes.

·       Dilation alone is ineffective unless preceded by surgical release.

Take-home points:

1. Identify the cause of stenosis before operating.

2. Dissect completely to the side walls and restore full caliber.

3. Combine surgery with disease-specific topical therapy.

4. Long-term success depends on strict postoperative dilation.

   
   

Þ   Prof. Yasukuni Yoshimura – Repair of Large Urethral Diverticulum with a Martius Flap

Prof. Yoshimura (Japan) presented a video case of a 56-year-old woman with a saddlebag-shaped urethral diverticulum (UD) diagnosed on MRI. His technique emphasized safe, stepwise dissection and reinforcement to minimize postoperative complications.

Key steps included:

·       Full-thickness incision in the correct plane, aided by hydrodissection and retraction.

·       Partial resection of the ventral UD wall, followed by closure of the ostium with Polyglactin Rapide suture.

·       Cauterization of the residual cavity to prevent recurrence.

·       Placement of a Martius fat pad graft, divided into two lobes: one fixed inside the cavity to prevent protrusion, the other wrapped around the ventral urethra like a “scarf” for reinforcement.

·       Meticulous closure of the periurethral fascia to preserve continence.

In a series of >40 cases, this approach yielded excellent symptom resolution and minimal postoperative stress urinary incontinence, sys Prof. Yoshimura. While total UD excision remains the traditional standard due to concerns of malignancy, Dr. Yoshimura highlighted that malignancy is exceedingly rare and that his technique may reduce morbidity in selected cases.

Þ   Prof. Judith Goh – Complex Urogenital Fistula Repair in Resource-Limited Settings

Prof. Goh presented three challenging cases, focusing on practical surgical strategies that can be applied in low- and middle-income countries.

1. Circumferential Fistula

·       Cause: Severe pressure necrosis resulting in complete separation of the urethra and bladder from the vaginal tissue.

·       Key steps: Careful mobilization of bladder and vagina, followed by tension-free re-anastomosis of the bladder to the urethra using 2/0 polyglycan sutures with a curved needle.

·       A metal catheter is used to guide the repair and prevent urethral closure; a dye test confirms watertight closure.

·       Postoperative catheterization is maintained for two weeks.

2. Vaginal Closure of Cervicovesical Fistula

·       Etiology: Typically a combined obstetric and iatrogenic injury.

·       Approach: A transverse vaginal incision, similar to that in vaginal hysterectomy, provides access while avoiding dense abdominal adhesions.

·       Fistula identification is facilitated by a metal catheter or methylene blue instillation.

·       Closure is performed in one or two layers with 2/0 interrupted polyglycan sutures, sometimes combined with repair of anterior cervical tears.

·       Postoperative catheterization is maintained for two weeks.

·       The procedure is low-cost and feasible under spinal anesthesia.

3. Chronic 4th-Degree Obstetric Anal Sphincter Injury

·       Presentation: Lateral tissue displacement and fusion, often with pouting rectal mucosa. The internal sphincter cannot be separated due to scarring and fusion.

·       Surgical steps: Identify introital margins, incise at the mucocutaneous junction, mobilize the rectum from the vagina, and carefully identify remnants of the external anal sphincter.

·       Overlapping two-layer closure with continuous polyglycan sutures restores sphincter function.

·       Intraoperative rectal palpation helps distinguish sphincter tissue from superficial perineal muscles.

Prof. Goh emphasized meticulous dissection, tension-free multilayer closure, intraoperative guidance with catheters or probes, and postoperative catheterization. These principles provide safe, effective, and reproducible outcomes in resource-limited environments.

Þ   Dr. Marcus Carey – Abdominal Native Tissue Repair for POP and SUI

Dr. Carey presented advanced techniques for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) using autologous fascia lata (AFL) grafts as an alternative to synthetic mesh.

Graft Harvesting

·       Performed through a 3–4 cm skin incision. A 12 × 4 cm strip of fascia lata is harvested by blunt and finger dissection.

·       The graft is prepared by latticing, increasing its width by ~50% to improve coverage and tissue integration.

·       Harvest typically takes 15–20 minutes. Wound closure is followed by a pressure dressing and a six-week compression garment to reduce seroma formation.

Indications for AFL Use

·       Sacrocolpopexy (post-hysterectomy or concomitant with hysterectomy)

·       Sacral hysteropexy

·       Ventral rectopexy

·       Transvaginal anterior and/or apical repair

·       SUI pubovaginal sling, particularly in patients with prior mesh complications, pelvic radiation, or immunosuppression.

Graft Placement

·       The prepared graft is introduced vaginally, primarily along the anterior vaginal wall, covering two-thirds to three-quarters of its length down to the bladder neck.

·       It is tacked to the vaginal apex and anterior wall with delayed absorbable sutures (2-0 PDS), avoiding permanent sutures.

·       On the sacrum, the graft is anchored midline to the anterior longitudinal ligament, taking care to avoid vascular structures and the lumbosacral disc.

·       The peritoneum is routinely closed over the graft.

Clinical Outcomes

·       Long-term follow-up shows that AFL grafts remain pliant and maintain excellent pelvic support, while synthetic mesh may retract or elongate unpredictably, leading to suboptimal results.

·       Autologous graft use combined with meticulous technique offers superior long-term safety and efficacy compared with mesh.

Additional Surgical Approaches

·       Sacral Colpopexy with AFL: If the sacral promontory is inaccessible, vaginal access is preferred. Dissection is focused on the anterior vaginal wall to the bladder neck, minimizing posterior dissection.

·       Uterosacral Ligament Suspension: Performed laparoscopically or robotically (preferred). Suturing each ligament minimizes risk of ureteric kinking and provides durable support, with good integrity demonstrated beyond one year. In 128 patients, outcomes showed reliable apical support without mesh.

·       Burch Colposuspension: A mesh-free, native tissue option for SUI. Through a suprapubic incision, the anterior vaginal wall is re-supported beneath the urethra with permanent sutures to Cooper’s ligament, reducing the vagina–ligament distance from ~7 cm to 3–4 cm. Careful tensioning prevents obstruction and secondary prolapse.

Dr. Carey underscored the importance of careful dissection, thoughtful graft preparation, precise placement, and avoidance of permanent mesh to maximize long-term safety and outcomes.

1st Place Video from Surgical Video Competition

The Y technique for labiaplasty with clitoral hood reduction involves marking excess tissue, performing a superficial resection, and closing in a Y-shaped fashion with absorbable sutures. This method ensures tension-free healing, excellent cosmetic outcomes, and high patient satisfaction, offering a simple and effective surgical option.

2nd Place Video from Surgical Video Competition

A 73-year-old woman with a history of transvaginal mesh placement for prolapse developed recurrent intravesical mesh erosion with stone formation. She underwent robotic mesh excision with left ureteral reimplantation. The procedure included cystotomy, complete mesh removal, two-layer bladder closure, and tension-free ureteral reanastomosis. Postoperative evaluation confirmed intact healing, preserved renal function, and absence of residual mesh or stones, with resolution of urinary symptoms.