Obstetricians & Gynecologists
23 years of experience
Video profile
Accepting new patients
Northwest Dallas
Univ TX Southwestern Med Ctr
5323 Harry Hines Blvd
Dallas, TX 75390
214-645-3848
Locations and availability (3)

Education ?

Medical School Score Rankings
University of Cincinnati (1987)
  • Currently 3 of 4 apples
Top 50%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Uterine Prolapse
CREOG National Faculty Award for Excellence in Resident Education
Faculty Teaching Award (1996)
Outstanding Faculty Award (1999)
CREOG National Faculty Award for Excellence in Resident Education (1999)
Associations
American Board of Obstetrics and Gynecology
American Urogynecologic Society

Affiliations ?

Dr. Schaffer is affiliated with 7 hospitals.

Hospital Affilations

Score

Rankings

  • UT Southwestern University Hospital - Zale Lipshy
    5151 Harry Hines Blvd, Dallas, TX 75235
    • Currently 4 of 4 crosses
    Top 25%
  • UT Southwestern University Hospital - St. Paul
    5909 Harry Hines Blvd, Dallas, TX 75235
    • Currently 4 of 4 crosses
    Top 25%
  • Parkland Health & Hospital System
    5201 Harry Hines Blvd, Dallas, TX 75235
    • Currently 1 of 4 crosses
  • St Paul Med Ctr
  • Dallas County Hospital District
  • UT Southwestern Zale Lipshy Hospital
  • Univ TX Southwestern Med Ctr
    5323 Harry Hines Blvd, Dallas, TX 75390
  • Publications & Research

    Dr. Schaffer has contributed to 35 publications.
    Title Urodynamic Indices and Pelvic Organ Prolapse Quantification 3 Months After Vaginal Delivery in Primiparous Women.
    Date February 2012
    Journal International Urogynecology Journal
    Excerpt

    This study aims to describe multichannel urodynamic indices and pelvic organ prolapse quantification (POP-Q) in primiparous women 3 months after vaginal delivery.

    Title Female Pelvic Medicine and Reconstructive Surgery. Preface.
    Date April 2010
    Journal Obstetrics and Gynecology Clinics of North America
    Title Pathophysiology of Pelvic Organ Prolapse.
    Date April 2010
    Journal Obstetrics and Gynecology Clinics of North America
    Excerpt

    The pathophysiology of pelvic organ prolapse is believed to be multifactorial. Several risk factors, such as childbirth and aging, have been identified. Suspected aberrations in the structure and function of the connective tissue, muscles, and nerves of the pelvic floor are still under investigation. In this article, the cellular, biochemical, and molecular basis of pelvic organ prolapse is discussed with a focus on the new theory of elastinopathy as an etiology of prolapse.

    Title Validation of Spanish Versions of the Pelvic Floor Distress Inventory (pfdi) and Pelvic Floor Impact Questionnaire (pfiq): a Multicenter Validation Randomized Study.
    Date August 2009
    Journal International Urogynecology Journal and Pelvic Floor Dysfunction
    Excerpt

    The purpose of this study is to validate Spanish versions of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ).

    Title Does Supracervical Hysterectomy Provide More Support to the Vaginal Apex Than Total Abdominal Hysterectomy?
    Date December 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to assess whether cervical preservation at the time of hysterectomy may help prevent subsequent apical vaginal vault prolapse. STUDY DESIGN: Supracervical hysterectomies were performed in 12 unembalmed cadavers. Successive hanging weights of 1, 2, 3, and 4 kg were loaded against the cervical stump and distances moved were recorded. The same process was repeated after completion of a total hysterectomy. RESULTS: Average distances pulled with 1, 2, 3, and 4 kg of traction against the cervical stump were 17.8 +/- 1.9, 24.1 +/- 2.5, 29.0 +/- 2.8, and 34.3 +/- 3.5 mm, respectively. After total hysterectomy, these distances were 17.5 +/- 2.5, 23.5 +/- 2.6, 29.3 +/- 3.1, and 34.5 +/- 3.6 mm, respectively. CONCLUSION: In unembalmed cadavers, it appears that total abdominal hysterectomy and supracervical hysterectomy provide equal resistance to forces applied to the vaginal apex.

    Title Neurovascular Anatomy of the Sacrospinous Ligament Region in Female Cadavers: Implications in Sacrospinous Ligament Fixation.
    Date December 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to further characterize the anatomy of the coccygeus muscle-sacrospinous ligament (C-SSL) complex and to correlate the findings with sacrospinous ligament fixations (SSLF). STUDY DESIGN: Dissections were performed in 21 female cadavers. RESULTS: In all dissections, nerves originating from S3, S4, S5, or a combination passed over the anterior surface of the C-SSL at its midsegment, and either the pudendal or third sacral nerve coursed on the superior border of C-SSL at its midpoint. In 100% of specimens, the internal pudendal artery (IPA) passed behind or just medial to the ischial spine. The average distance of the inferior gluteal artery (IGA) from the ischial spine and the superior border of the C-SSL was 24.2 (range, 15-35) mm and 3.4 (range, 1-5) mm, respectively. CONCLUSION: Nerves to the coccygeus and levator ani coursed over the midportion of the C-SSL where SSLF sutures are placed. The pudendal nerve and IGA were in proximity to the superior border of the C-SSL at its midportion, whereas the IPA passed behind the ischial spine, lateral to the recommended site for suture placement.

    Title Anatomic Relationships of the Distal Third of the Pelvic Ureter, Trigone, and Urethra in Unembalmed Female Cadavers.
    Date December 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to examine the relationship of the ureter to paravaginal defect repair (PVDR) sutures and to evaluate the anatomy of distal ureter, trigone, and urethra relative to the anterior vaginal wall. STUDY DESIGN: Dissections of the retropubic space were performed in 24 unembalmed female cadavers following placement of PVDR sutures. Lengths of the vagina, urethra, and trigone were recorded. RESULTS: The mean distance between apical PVDR sutures and the ureter was 22.8 (range, 5-36) mm. The average lengths of the urethra, trigone, and vagina were 3 cm, 2.8 cm, and 8.4 cm, respectively. The trigone was positioned over the middle third of the anterior vaginal wall in all specimens and the distal ureters traversed the anterolateral vaginal fornices. CONCLUSION: The ureters may be injured during paravaginal defect repairs, anterior colporrhaphies, and other procedures involving dissection in the upper third of the vagina. Cystotomy during vaginal hysterectomies is most likely to occur 2-3 cm above the trigone.

    Title Uterosacral Ligament Suspension Sutures: Anatomic Relationships in Unembalmed Female Cadavers.
    Date December 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to characterize anatomic relationships of uterosacral ligament suspension (USLS) sutures. STUDY DESIGN: The relationship of USLS sutures to the ureters, rectal lumen, and sidewall neurovascular structures was examined in 15 unembalmed female cadavers. RESULTS: The mean distance of the proximal sutures to the ureters and rectal lumen was 14 mm (range, 0-33) and 10 mm (range, 0-33), respectively. The mean distance of the distal sutures to the ureters was 14 mm (range, 4-33) and to the rectal lumen 13 mm (range, 3-23). Right sutures were noted at the level of S1 in 37.5%, S2 in 37.5%, and S3 in 25% of specimens. Left sutures were noted at the level of S1 in 50%, S2 in 29.2%, and S3 in 20.8% of cadavers. Of 48 sutures passed, 1 entrapped the S3 nerve. Sutures perforated the pelvic sidewall vessels in 4.1% of specimens. CONCLUSION: USLS sutures can directly injure the ureters, rectum, and neurovascular structures in the pelvic walls.

    Title The Natural History of Posterior Vaginal Wall Support After Abdominal Sacrocolpopexy with and Without Posterior Colporrhaphy.
    Date May 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to determine the degree of posterior vaginal wall support after abdominal sacrocolpopexy (ASC) with and without a posterior colporrhaphy as a function of time. STUDY DESIGN: Retrospective review was performed on women who underwent ASC between 1997 and 2004. Pelvic organ prolapse quantification (POP-Q) points Ap and Bp and stage of posterior compartment were collected at initial visit and at 1, 4, 10, 22, and 34 months after ASC. RESULTS: Significant improvement of POP-Q point Ap and Bp and stage of posterior compartment was initially seen after ASC with or without posterior colporrhaphy. With concomitant posterior colporrhaphy, the improvement in Ap persisted 34 months after surgery. Mean Bp and stage of the posterior compartment returned to preoperative values after 10 months, regardless of whether a concurrent posterior colporrhaphy had been performed. Fifty-one of 191 women (29%) had subsequent stage 2 posterior wall prolapse, 4 (2%) of whom underwent subsequent posterior colporrhaphy. CONCLUSIONS: For ASC with concomitant posterior colporrhaphy, POP-Q point Ap significantly improved and persisted at 34 months after surgery. Ten months after surgery, descent of POP-Q point Bp returned to preoperative levels and was the same regardless of whether a site-specific posterior colporrhaphy was performed at the time of an abdominal sacrocolpopexy.

    Title The Pessri Study: Symptom Relief Outcomes of a Randomized Crossover Trial of the Ring and Gellhorn Pessaries.
    Date April 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The aim of this randomized crossover trial was to compare symptom relief and change in life impact for women using the ring with support and Gellhorn pessaries. STUDY DESIGN: Subjects were randomized to use each pessary for 3 months. Outcome data included a visual analog satisfaction score, and quality of life questionnaires. Analysis included student's t-test, Wilcoxan Signed-rank test and logistical regression. RESULTS: Subjects were primarily white, parous, postmenopausal women with a mean age of 61. The median POPQ stage was III. We enrolled 134 subjects and collected 3-month data on 94 ring and 99 Gellhorn subjects. There were statistically and clinically significant improvements in the majority of the PFDI and many PFIQ scales with both pessaries, but no clinically significant differences between the two pessaries. CONCLUSIONS: The ring with support and Gellhorn pessaries are effective and equivalent in relieving symptoms of protrusion and voiding dysfunction.

    Title Vascular Anatomy of the Presacral Space in Unembalmed Female Cadavers.
    Date December 2006
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to characterize the vascular anatomy of the female presacral space (PSS) and to correlate findings to the abdominal sacrocolpopexy. STUDY DESIGN: Detailed dissections of the PSS were performed in 52 unembalmed female cadavers. RESULTS: The closest cephalad vessel to the mid sacral promontory (MSP) was the left common iliac vein (LCIV), mean distance 27 mm (9-52 mm). The closest vessel lateral to MSP was also the LCIV, mean distance 22 mm (9-35 mm). The average distance of the middle sacral artery and vein to the MSP was 4 mm (0-15 mm) and 7 mm (0-17 mm), respectively. The mean distance of the sacral venous plexuses to the MSP was 34 mm (4-86 mm). CONCLUSION: Anatomic location of the vascular boundaries and contents of the PSS is highly variable. Careful dissection and exposure of the anterior longitudinal ligament of the sacrum before suture placement should minimize potentially life-threatening vascular complications.

    Title Anatomical Path of the Tension-free Vaginal Tape: Reassessing Current Teachings.
    Date December 2006
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to revisit the anatomical path of the tension-free vaginal tape and better describe its relationship to the perineal membrane and other important anatomic landmarks. STUDY DESIGN: Dissections of the anterior perineal triangle, periurethral, and retropubic spaces were performed in 24 unembalmed female cadavers following placement of the tension-free vaginal tape to identify the sling's relationship to the perineal membrane, periurethral muscles, and the arcus tendineus fascia pelvis. RESULTS: In 100% of specimens, the device passed cephalad to the perineal membrane. The urethrovaginal sphincter muscle was perforated in 2 of the specimens. The sling passed lateral to the arcus tendineus and perforated the pubococcygeus muscle in 6 (25%) of the cadavers. In the remaining 18 (75%) specimens, the mesh was medial to the arcus tendineus and penetrated the periurethral connective tissue. CONCLUSION: The assertion that the tension-free vaginal tape perforates the perineal membrane is incorrect.

    Title Prevalence of Severe Pelvic Organ Prolapse in Relation to Job Description and Socioeconomic Status: a Multicenter Cross-sectional Study.
    Date November 2006
    Journal International Urogynecology Journal and Pelvic Floor Dysfunction
    Excerpt

    The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

    Title A Randomized Trial of Coached Versus Uncoached Maternal Pushing During the Second Stage of Labor.
    Date April 2006
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of this study was to compare obstetrical outcomes associated with coached versus uncoached pushing during the second stage of labor. STUDY DESIGN: Upon reaching the second stage, previously consented nulliparous women with uncomplicated labors and without epidural analgesia were randomly assigned to coached (n = 163) versus uncoached (n = 157) pushing. Women allocated to coaching received standardized closed glottis pushing instructions by certified nurse-midwives with proper ventilation encouraged between contractions. These midwives also attended those women assigned to no coaching to ensure that any expulsive efforts were involuntary. RESULTS: The second stage of labor was abbreviated by approximately 13 minutes in coached women (P = .01). There were no other clinically significant immediate maternal or neonatal outcomes between the 2 groups. CONCLUSION: Although associated with a slightly shorter second stage, coached maternal pushing confers no other advantages and withholding such coaching is not harmful.

    Title Vascular Anatomy over the Superior Pubic Rami in Female Cadavers.
    Date March 2006
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to characterize the vascular anatomy over the superior pubic ramus. STUDY DESIGN: Detailed dissections of the retropubic space were performed in 15 fresh female cadavers. Vessels crossing the superior pubic rami were inspected for width, course, communications, and relationship to the midline of the pubic symphysis and the obturator canal. RESULTS: Vessels 1 mm or greater in width connecting the obturator vessels and inferior epigastric or external iliac vessels were noted in 10 of 15 (66.7%) cadavers: 9 (60%) had veins, 5 (33.3 %) had arteries, and 4 (26.7%) had both. In all specimens, the vessels crossed over the superior pubic rami lateral to or at the level of the obturator canal, which was on average 5.4 cm from the midline of the pubic symphysis. CONCLUSION: Communicating vessels crossing the superior pubic rami were present in the majority of specimens. Understanding this anatomy should aid the surgeon in avoiding vascular complications.

    Title Etiology of Pelvic Organ Prolapse.
    Date January 2006
    Journal Clinical Obstetrics and Gynecology
    Title Predicting Bacteriuria in Urogynecology Patients.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: This study was undertaken to determine whether reagent strip testing can predict bacteriuria in urogynecology patients. STUDY DESIGN: All women undergoing urodynamic evaluations from June 1997 to October 2001 were identified by using a computerized database. Urine culture results were compared with reagent strip testing. Significant bacteriuria was defined as greater than 10(5) colony-forming units per milliliter. RESULTS: Bacteriuria prevalence was 8.6% (n = 51). Sensitivity and specificity of nitrites were 0.51, (95% CI, 0.31-0.66) and 0.991, (95% CI, 0.974-0.998), respectively. Blood had a lower sensitivity (0.35, 95% CI, 0.20-0.54) and specificity (0.80, 95% CI, 0.75-0.84). Leukocyte esterase was similar to blood with a sensitivity of 0.28 (95% CI, 0.14-0.45) and specificity of 0.83 (95% CI, 0.78-0.87). No combination of tests offered improved sensitivity or specificity over nitrites alone. CONCLUSION: Nitrite dipstick testing has excellent specificity for bacteriuria in urogynecologic patients. These results support the treatment of women with positive nitrites who are preparing to undergo urodynamics without obtaining culture.

    Title Pelvic Organ Support Study (posst) and Bowel Symptoms: Straining at Stool is Associated with Perineal and Anterior Vaginal Descent in a General Gynecologic Population.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to evaluate the association of constipation symptoms and anal incontinence with vaginal wall and pelvic organ descent in a general gynecologic population. STUDY DESIGN: In this multicenter, cross-sectional study, 1004 women attending routine gynecologic healthcare underwent pelvic organ prolapse quantification (POPQ) measurements, and were surveyed regarding anal incontinence, digitation, < 2 bowel movements (BMs)/week, and > 25% frequency of: straining, hard/lumpy stools, and incomplete emptying. Constipation scores reflected the sum of positive responses. Associations between POPQ measurements (Ba, C, Bp, gh+pb), constipation scores, and anal incontinence were evaluated using multivariable regression. RESULTS: Of 119 women with Bp > or = -1.00, 47% reported no constipation symptoms. Hard/lumpy stools (26%), incomplete emptying (24%), and straining (24%) were more prevalent; fewer women reported < 2 BMs/week (15%) or digitation (7%). Constipation scores were weakly correlated with Bp, gh+pb (both r < .1, P < .02). Women reporting > or = 2 symptoms had greater gh+pb measurements than women reporting 0 or 1 symptom (P = .03). Women with anal incontinence had greater gh+pb and gh values than women without anal incontinence (P < .01). POPQ measurements were regressed separately onto (1) total constipation scores, (2) dichotomized scores, and (3) individual symptoms, with BMI, age, number of vaginal deliveries (NVD), weight of largest vaginal delivery (WLVD), race, hysterectomy, study site, and income included as covariates. Total constipation scores and dichotomized scores were nonsignificant in all models. With regard to individual symptoms, straining at stool was significant in the models for Ba and gh+pb, with greater Ba and gh+pb measurements among strainers relative to nonstrainers. CONCLUSION: Most associations between bowel symptoms and vaginal or pelvic organ descent were weak. After controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent.

    Title Anal Incontinence in Women Presenting for Gynecologic Care: Prevalence, Risk Factors, and Impact Upon Quality of Life.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to estimate the prevalence and impact upon quality of life of anal incontinence (AI) in women aged 18 to 65. STUDY DESIGN: Consecutive women presenting for general gynecologic care were given a bowel function questionnaire. Women with AI were prompted to complete the Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The cohort was composed of 457 women with a mean age of 39.9 +/- 11 years. AI prevalence was 28.4% (95% CI 24.4-32.8). After logistic regression, IBS (OR 3.22, 1.75-5.93), constipation (OR 2.11, 1.22-3.63), age (OR 1.05, 1.03-1.07), and BMI (OR 1.04, 1.01-1.08) remained significant risk factors. The mean FISI score was 20.4 +/- 12.4. Women with only flatal incontinence scored higher, and women with liquid loss scored lower on all 4 scales of the FIQL. CONCLUSION: AI is prevalent in women seeking benign gynecologic care, and liquid stool incontinence has the greatest impact upon quality of life.

    Title Obstetric Antecedents for Postpartum Pelvic Floor Dysfunction.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth. STUDY DESIGN: All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated. RESULTS: During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01). CONCLUSION: The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.

    Title A Randomized Trial of the Effects of Coached Vs Uncoached Maternal Pushing During the Second Stage of Labor on Postpartum Pelvic Floor Structure and Function.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine if refraining from coached pushing during the second stage of labor affects postpartum urogynecologic measures of pelvic floor structure and function. STUDY DESIGN: Nulliparous women at term were randomized to coached (n = 67) vs uncoached (n = 61) pushing. At 3 months' postpartum women underwent urodynamic testing, pelvic organ prolapse examination (POPQ), and pelvic floor neuromuscular assessment. RESULTS: Urodynamic testing revealed decreased bladder capacity (427 mL vs 482 mL, P = .051) and decreased first urge to void (160 mL vs 202 mL, P = .025) in the coached group. Detrusor overactivity increased 2-fold in the coached group (16% vs 8%), although this difference was not statistically significant (P = .17). Urodynamic stress incontinence was diagnosed in the coached group in 11/67 (16%) vs 7/61 (12%) in the uncoached group (P = .42). CONCLUSION: Coached pushing in the second stage of labor significantly affected urodynamic indices, and was associated with a trend towards increased detrusor overactivity.

    Title Urethral Erosion of Tension-free Vaginal Tape Presenting As Recurrent Stress Urinary Incontinence.
    Date February 2005
    Journal International Urogynecology Journal and Pelvic Floor Dysfunction
    Excerpt

    The suburethral sling with tension-free vaginal tape (TVT) has become a popular treatment for stress urinary incontinence. Erosion of the mesh into the urethra is rare, usually presenting with hematuria, pain, voiding dysfunction or urge incontinence. A patient with stress incontinence was treated with a TVT suburethral sling. One month later, symptoms of recurrent stress incontinence developed. Cystourethroscopy revealed urethral mesh erosion. Surgical removal involved cystourethroscopic-assisted transurethral resection of the mesh, followed by vaginal dissection and periurethral withdrawal. Urethral mesh erosion should be considered in a patient who presents with atypical symptoms after being treated with a suburethral sling. It is important to obtain a detailed history and have a high clinical index of suspicion for erosion. Careful and comprehensive urethroscopy, in addition to cystoscopy, should be a mandatory part of the TVT procedure. Further study is needed to determine the optimal technique for mesh removal.

    Title Effect of Periurethral Denervation on Smooth Muscles of the Lower Urinary Tract.
    Date January 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: This study was undertaken to determine the effect of periurethral denervation on contractile function of the smooth muscle of the lower urinary tract of the female rat. STUDY DESIGN: Periurethral nerve transection or sham operation was performed in 35 young female rats. Contractile function of the bladder dome and base was determined as a function of time after surgery. Statistical analysis was conducted by Student t test. RESULTS: Periurethral denervation resulted in impaired contractile responses to electrical field stimulation in the bladder base (nerve-transected 45 +/- 11 g/cm 2 ; sham 84 +/- 10 g/cm 2 , P < .05) and dome (nerve-transected 179 +/- 16 g/cm 2 ; sham 334 +/- 29 g/cm 2 , P < .05) 2 weeks after nerve transection. The ability to respond to potassium chloride and the muscarinic agonist, carbachol, and the rates of contraction and relaxation, however, remained intact. Baseline phasic contractile activity was increased significantly in bladders from nerve-transected animals. Maximal field-stimulated contractions of the longitudinal urethra smooth muscle were not altered by periurethral denervation (sham 21 +/- 6 g/cm 2 , nerve-transected 19 +/- 5 g/cm 2 , P = .4). Compromised nerve-mediated contractions of the bladder dome and base improved significantly by 21 days. CONCLUSION: Periurethral nerve transection results in transient impairment of neurogenic contractile responses in the bladder base and dome, though the intrinsic ability of the bladder to contract remains intact. This compromised response of the dome, in conjunction with previous results demonstrating impaired urethral smooth muscle relaxation, suggests that transection of periurethral neurons may have complex effects on the entire lower urinary tract.

    Title Multiple Vaginal Wall Cysts: Diagnosis and Surgical Management.
    Date June 2004
    Journal Obstetrics and Gynecology
    Excerpt

    BACKGROUND: Simple cysts of the female genital tract may become symptomatic and require surgical removal. CASE: A 20-year-old woman had complaints of a vaginal bulge, pelvic pressure, dyspareunia, and stress urinary incontinence. Two cystic masses were seen in the vagina. A magnetic resonance imaging scan revealed 2 additional larger cysts. Urodynamic evaluation was significant for stress incontinence at 200 mL and a Valsalva leak-point pressure of 51 cm H(2)0. The 2 smaller cysts were removed intact through a superficial incision. The larger cysts were intentionally ruptured and dissected out. Histologic examination revealed a low cuboidal or a ciliated columnar epithelium that stained positive with mucicarmine, consistent with müllerian origin. One year after surgical excision, the patient remained symptom free with no urinary incontinence and no recurrence of the cysts. CONCLUSION: Magnetic resonance imaging was useful in delineating the course and anatomic arrangement of the vaginal cysts, but more importantly, identified another cyst that was not readily apparent at physical examination.

    Title Effect of Periurethral Denervation on Function of the Female Urethra.
    Date January 2004
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the effect of periurethral denervation on contractile function of the female rat urethra. STUDY DESIGN: Periurethral nerve transection or sham operation was performed in 16 young female rats. After 2 weeks, contractile function of the external urethra sphincter (EUS) and longitudinal smooth muscle was determined. Inhibitors of nitric oxide (NO) signaling were used to evaluate the role of nitric oxide in nerve-mediated relaxation. Statistical comparisons were conducted by Student t test. RESULTS: Periurethral nerve transection resulted in gross evidence of urinary retention and bladder distention. In normal and sham-operated rats, nerve-mediated relaxation of urethral smooth muscle was inhibited by L-nitroarginine and oxadiazolo quinoxalin-1-one (ODQ), and this relaxation response was impaired significantly after periurethral nerve injury. Relaxation responses to the NO donor sodium nitroprusside remained intact. Contractile function of the EUS was not altered by periurethral nerve injury. CONCLUSION: Neurons surrounding the urethra contain NO and innervate smooth muscle of the inner urethra. Periurethral denervation results in impaired urethral smooth muscle relaxation with no appreciable effect on contractility of the external striated sphincter.

    Title A Comprehensive Pelvic Dissection Course Improves Obstetrics and Gynecology Resident Proficiency in Surgical Anatomy.
    Date November 2003
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: This study was undertaken to evaluate the impact of a pelvic dissection course on resident proficiency in surgical anatomy. STUDY DESIGN: Over a 1-year period, residents attended a course consisting of pretesting and posttesting, lectures, and pelvic dissection. Tests results were analyzed using paired Student t test, analysis of variance, and Kruskal-Wallis statistics. RESULTS: Of 42 residents, 24 completed all testing (study cohort). On written and practical examinations, resident scores improved a median of 42% and 29% (both P<.0001). Postgraduate year (PGY) 2 demonstrated the greatest improvement on the practical and PGY-3s demonstrated the greatest improvement on the written. Baseline written and practical results discriminated PGY level (construct validity): PGY-2=PGY-3<PGY-4 on written pretest, PGY-2<PGY-3=PGY-4 on practical pretest. No difference between resident cohorts was seen in either posttest. CONCLUSION: Resident surgical anatomy proficiency is measurably improved by a comprehensive course.

    Title Multiple Vesical Calculi and Complete Vaginal Vault Prolapse.
    Date November 2003
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Multiple-vessel calculi in the setting of pelvic organ prolapse is rare. Long-standing prolapse and bladder outlet obstruction, coupled with chronic infection are suspected to be the inciting factors in this case. To remove the calculi, an open cystolithotomy was performed at the time of an abdominal anti-incontinence procedure.

    Title Morphometric Properties of the Posterior Vaginal Wall in Women with Pelvic Organ Prolapse.
    Date January 2003
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to analyze the morphometric properties of the posterior vaginal wall and compare the smooth muscle distribution in the posterior vaginal muscularis in women with and without pelvic organ prolapse. STUDY DESIGN: Specimens were taken from the apex of the posterior vaginal wall after hysterectomy from 15 women with pelvic organ prolapse and from 8 healthy control subjects. Smooth muscle cells of the posterior vaginal wall were identified by immunohistochemistry with antibodies to smooth muscle alpha-actin. Morphometric analysis was performed on histologic cross-sections of the posterior vaginal wall to determine the fractional area of nonvascular smooth muscle in the muscularis. The innervation pattern of the vaginal wall was determined by use of S100 immunostaining. Statistical comparisons between two groups were conducted by a Student t test. Comparisons between multiple groups were conducted with a one-way analysis of variance followed by a post-hoc Student-Neuman-Keuls test. RESULTS: The fractional area of nonvascular vaginal smooth muscle in the muscularis of women with posterior wall prolapse was significantly decreased compared with that of healthy control subjects. Nerve bundles were located in the deep vaginal muscularis and adventitia of the posterior vaginal wall. In women with posterior wall prolapse, nerve bundles were smaller and fewer in number. CONCLUSION: Morphologic features of the posterior vaginal wall are significantly altered in women with posterior wall prolapse compared with asymptomatic control subjects.

    Title Hysterectomy--still a Useful Operation.
    Date October 2002
    Journal The New England Journal of Medicine
    Title Morphometric Analysis of Smooth Muscle in the Anterior Vaginal Wall of Women with Pelvic Organ Prolapse.
    Date July 2002
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to compare the smooth muscle content of the anterior vaginal wall in normal women and women with pelvic organ prolapse. STUDY DESIGN: Specimens were taken from the apex of the anterior vaginal cuff after abdominal hysterectomy from 28 women with pelvic organ prolapse and 12 control subjects. Smooth muscle cells of the anterior vaginal wall were identified by immunohistochemistry with antibodies to smooth muscle alpha-actin. Morphometric analysis was used to determine the fractional area of nonvascular smooth muscle in the muscularis in histologic cross-sections of the anterior vaginal wall. RESULTS: The fractional area of nonvascular vaginal smooth muscle in the muscularis of women with prolapse was significantly decreased compared with that of control subjects. This decreased fraction of smooth muscle in the anterior vaginal wall was not related to age, race, or stage of prolapse. In women with prolapse, vaginal smooth muscle content was most diminished in specimens from postmenopausal women with no estrogen replacement. The fractional area of muscularis smooth muscle was also decreased significantly in premenopausal women with prolapse. CONCLUSION: The fraction of smooth muscle in the muscularis of the anterior vaginal wall is significantly decreased in women with pelvic organ prolapse compared with normal control subjects.

    Title Smooth Muscle Myosin Heavy Chain and Caldesmon Expression in the Anterior Vaginal Wall of Women with and Without Pelvic Organ Prolapse.
    Date December 2001
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The aim of this study was to quantify the expression of smooth muscle myosin heavy chain (SM-MHC) and caldesmon in the anterior vaginal wall of women with and without pelvic organ prolapse. STUDY DESIGN: Immunoblot analysis was conducted on protein extracts from the vaginal muscularis of 15 women with and 11 women without pelvic organ prolapse by using specific antibodies for SM-MHC, nonmuscle MHC-B, and caldesmon. The fraction of muscularis containing smooth muscle was determined by morphometric analysis of histologic cross sections. Reverse transcriptase-polymerase chain reaction was used to amplify SM-MHC isoforms produced by alternative splicing in the myosin head. RESULTS: Whereas the expression of SM-MHC was increased modestly (2-fold), expression of smooth muscle caldesmon was increased 6- to 7-fold in vaginal muscularis from women with prolapse. The relative distribution of SM-MHC isoforms was similar in both groups. CONCLUSIONS: Caldesmon is increased substantially in vaginal smooth muscle of women with pelvic organ prolapse. Caldesmon inhibits actin-activated myosin magnesium adenosine triphosphatase activity and inhibits the maintenance of contractile force. Thus, this disproportionate increase in caldesmon, relative to myosin, may result in inhibition of vaginal smooth muscle contractility and force maintenance.

    Title Tubo-ovarian Abscess Formation in Users of Intrauterine Devices Remote from Insertion: a Report of Three Cases.
    Date
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    Background: The association between tubo-ovarian abscess formation and the presence of an intrauterine device (IUD) is well recognized. It has been suggested that the risk of upper-genital-tract infection is highest during the immediate period following the insertion of an IUD, returning to baseline by 5 months postinsertion. We present 3 cases of women who, 10-21 years after insertion of their IUDs, developed tubo-ovarian abscesses that were not causally related to sexually transmitted diseases (STDs) or actinomycetes.Cases: Three women, ages 39-47 years, presented to our gynecology service for evaluation of abdominal pain. One woman had bilateral tubo-ovarian abscesses and the other 2 had unilateral tubo-ovarian abscesses. All 3 were IUD users, with an interval from IUD insertion to presentation of 10-21 years. In each case, the cervical cultures for gonorrhea and chlamydia were negative at presentation and the sexual history was not consistent with an STD mode of spread. All 3 women initially received broad-spectrum antibiotics, but 2 eventually required definitive surgical therapy.Conclusion: Long-term users of IUDs remain at risk for serious, indolent pelvic infections. These women should be counseled by their gynecologists on an ongoing basis as to this persistent risk. Tubo-ovarian abscess should be strongly considered in the differential diagnosis of an IUD user who presents with an adnexal mass, fever, or abdominal pain.

    Title Bilateral Ureteric Obstruction of a Partially Duplicated Collecting System Improves After Surgical Correction of Procidentia: a Case Report.
    Date
    Journal The Journal of Reproductive Medicine
    Excerpt

    BACKGROUND: Although the association between pelvic organ prolapse and upper urinary tract dilation has been documented, the causal relationship between the two has not been established. We report an improvement in severe hydronephrosis and hydroureter of a partially duplicated urinary collecting system after surgical correction of procidentia. CASE: A 52-year-old woman presented with radiologic evidence of a partially duplicated right collecting system with right-sided hydronephrosis and bilateral hydroureter in the setting of stage IV uterovaginal prolapse. A therapeutic trial of pessary placement failed to resolve the upper urinary tract dilation. The patient underwent abdominal hysterectomy, bilateral salpingo-oophorectomy, sacrocolpopexy, mid-urethral sling placement and posterior colporrhaphy. Repeat intravenous urography 4 weeks after surgery demonstrated interval resolution of the hydronephrosis. CONCLUSION: An improvement in hydronephrosis after surgical correction supports a cause-and-effect relationship between pelvic organ prolapse and obstructive uropathy.

    Title Graft Use in Transvaginal Pelvic Organ Prolapse Repair: a Systematic Review.
    Date
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To estimate the anatomic and symptomatic efficacy of graft use in transvaginal prolapse repair and to estimate the rates and describe the spectrum of adverse events associated with graft use. DATA SOURCES: Eligible studies, published between 1950 and November 27, 2007, were retrieved through Medline and bibliography searches. METHODS OF STUDY SELECTION: To assess anatomic and symptomatic efficacy of graft use, we used transvaginal prolapse repair studies that compared graft use with either native tissue repair or repair with a different graft. To estimate rates of adverse events from graft use, all comparative studies and case series with at least 30 participants were included. For spectrum of adverse events, all study designs were included. TABULATION, INTEGRATION AND RESULTS: Eligible studies were extracted onto standardized forms by one reviewer and confirmed by a second reviewer. Comparative studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic-absorbable, synthetic nonabsorbable) and outcome (anatomic, symptomatic). We found 16 comparative studies, including six randomized trials, 37 noncomparative studies with at least 30 women, 11 case series with fewer than 30 women, and 10 case reports of adverse events. One randomized trial and one prospective comparative study evaluating synthetic, nonabsorbable graft use in the anterior compartment reported favorable anatomic and symptomatic outcomes with graft use. Data regarding graft use for posterior and apical compartments or for biologic or synthetic absorbable graft use in the anterior compartment were insufficient to determine efficacy. Rates and spectrum of adverse events associated with graft use included bleeding (0-3%), visceral injury (1-4%), urinary infection (0-19%), graft erosion (0-30%), and fistula (1%). There were insufficient data regarding dyspareunia, sexual, voiding, or defecatory dysfunction. CONCLUSION: Overall, the existing evidence is limited to guide decisions regarding whether to use graft materials in transvaginal prolapse surgery. Adequately powered randomized trials evaluating anatomic and symptomatic efficacy as well as adverse events are needed.

    Title Systematic Review Highlights Difficulty Interpreting Diverse Clinical Outcomes in Abnormal Uterine Bleeding Trials.
    Date
    Journal Journal of Clinical Epidemiology
    Excerpt

    (1) To systematically collect and organize into clinical categories all outcomes reported in trials for abnormal uterine bleeding (AUB); (2) to rank the importance of outcomes for patient decision making; and (3) to improve future comparisons of effects in trials of AUB interventions.


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