Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

Surgeries for Pelvic Floor Disorders

43–1. Mandatory components to a rigid cystoscope include all EXCEPT which of the following?

a. Bridge

b. Camera

c. Sheath

d. Telescope and light source

43–2. Which rigid telescope most easily permits visualization of the lateral, anterior, and posterior bladder walls during diagnostic cystoscopy?

a. 0-degree lens

b. 30-degree lens

c. 70-degree lens

d. 120-degree lens

43–3. In this figure, the retropubic space is shown with two sutures on either side of the urethra. The first sutures are at the level of the urethrovesical junction, and the second are near the proximal third of the urethra. These are tied to the ipsilateral iliopectineal ligament (Cooper ligament). All EXCEPT which of the following are true regarding this procedure?


Reproduced, with permission, from Tarnay CM, Bhatia NN: Urinary incontinence. In DeCherney AH, Nathan L (eds): CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10th ed. New York, McGraw-Hill, 2007, Figure 45-6A.

a. Brisk bleeding in this operative space is likely due to laceration of vessels within the plexus of Santorini.

b. The patient is placed in candy-cane stirrups or Allen stirrups in high lithotomy position for this procedure.

c. Symptomatic success or cure in treatment of stress urinary incontinence is achieved in approximately 85 percent of patients.

d. Overcorrection of the urethrovesical angle (i.e., not leaving a suture bridge) has been suggested as a cause of postoperative voiding dysfunction.

43–4. Indications for the tension-free vaginal tape procedure include all EXCEPT which of the following?

a. Urge urinary incontinence

b. Prior failed anti-incontinence procedure

c. Stress urinary incontinence related to urethral hypermobility

d. Stress urinary incontinence related to intrinsic sphincteric deficiency

43–5. Risks associated with the transobturator tape sling include all EXCEPT which of the following?

a. Groin pain

b. Bleeding in the space of Retzius

c. Postoperative urgency incontinence

d. Postoperative voiding dysfunction, urinary retention

43–6. Which of the following statements regarding urethral bulking injection is correct?

a. It requires general anesthesia in the operating room.

b. Autologous fat is the most commonly used bulking agent.

c. Its success and cure rates for stress urinary incontinence are equivalent to those seen using midurethral slings.

d. None of the above

43–7. All EXCEPT which of these statements regarding urethrolysis are true?

a. The usual indication is bladder hypotonia.

b. Antibiotic prophylaxis is generally given.

c. Performing preoperative urodynamic studies is appropriate.

d. It may be performed transvaginally or abdominally depending on the route of the original antiincontinence surgery.

43–8. Which of these is NOT an approach to urethral diver-ticulum repair?

a. Latzko vaginal repair

b. Spence marsupialization

c. Complete diverticulectomy

d. Partial diverticular ablation

43–9. In the United States, most vesicovaginal fistulas are associated with which of the following?

a. Obstetric trauma

b. Pelvic radiation therapy

c. Prior hysterectomy for benign causes

d. Hysterectomy related to gynecologic malignancy

43–10. Regarding the timing of vesicovaginal fistula repair identified after hysterectomy, which statement is correct?

a. Surrounding tissue infection or inflammation must be absent.

b. Repair may be completed within the first few days posthysterectomy.

c. Repair may be completed after a delay of 4 to 6 weeks after the initial surgery.

d. All of the above

43–11. Which surgical steps would be recommended for the transvaginal repair of the fistula demonstrated here?


Reproduced, with permission, from Tanagho EA: Disorders of the bladder, prostate, and seminal vesicles. In Tanagho EA, McAninch JW (eds): Smith’s General Urology, 17th ed. New York. McGraw-Hill, 2008, Figure 37-3.

a. Cystoscopy to demonstrate ureteral patency

b. Placement of ureteral stents if ureters are close to the fistula

c. Placement of a pediatric urethral catheter through the fistulous opening

d. All of the above

43–12. When attempting a transvaginal repair of a vesicovaginal fistula that resulted from prior irradiation and in which vaginal tissues are fibrotic, which of the following techniques is the most appropriate to consider?

a. Inject a fibrin sealant via the cystoscope

b. Use a vascular graft such as the bulbocavernosus fat pad

c. Minimize approximation of the vaginal fibromuscular layer

d. Create increased tension along a rapidly absorbable suture line

43–13. Sacral neuromodulation has all EXCEPT which of the following indications?

a. Urinary urgency

b. Urinary frequency

c. Urge urinary incontinence

d. Obstructive urinary retention

43–14. What is the key reason to consider preoperative urodynamic testing for a continent woman planning the anterior vaginal wall surgery pictured below?


a. To predict those at highest risk for prolapse recurrence

b. To minimize the high risk of ureteral entrapment / injury that is associated with this procedure

c. To “unmask” those patients with “occult” incontinence so as to consider a concomitant anti-incontinence procedure

d. None of the above

43–15. Which of the following statements regarding the abdominal paravaginal repair is true?

a. It provides support to the distal anterior vagina.

b. It is an effective treatment for stress urinary incontinence.

c. It is useful for correction of midline defects in the anterior vaginal wall.

d. It is commonly performed in conjunction with the Burch colposuspension or other retropubic urethropexy.

43–16. The patient pictured below presents complaining of the need to manually reduce the bulge by pushing her fingers inside the vagina every time she has to defecate—especially when she is constipated. Which of the following statements regarding the procedure used to correct this defect is correct?


Photograph contributed by Dr. Marlene Corton.

a. Concomitant perineorrhaphy is rarely necessary.

b. There is significant risk of ureteral entrapment or injury.

c. Placement of plication sutures too far laterally may result in dyspareunia.

d. Correction of the bulge should reliably improve the patient’s constipation.

43–17. Compared with traditional restorative transvaginal procedures for correcting apical vaginal prolapse, which of the following is true regarding the abdominal route pictured below?


Reproduced, with permission, from Schaffer JI, Hoffman BL: Surgeries for female pelvic reconstruction. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 42-17.7.

a. Has a higher risk of failure

b. Tends to shorten the vaginal length

c. Creates a mobile vaginal apex, thereby possibly decreasing the risk of dyspareunia

d. Should only be used for recurrent prolapse after other failed prolapse surgeries

43–18. Which of the following describes the best graft material for most patients undergoing abdominal sacrocolpopexy?

a. Cadaveric fascia

b. Monofilament synthetic mesh with large pore size

c. Multifilament synthetic mesh with small pore size

d. Autologous fascia such as fascia lata or rectus fascia

43–19. Risks associated with vaginal uterosacral ligament suspension may include which of the following?

a. Ureteral kinking and injury

b. Nerve injury and subsequent neuropathy

c. Shortening and fixation of the upper vagina with postoperative dyspareunia

d. All of the above

43–20. Which of the following is true of the sacrospinous ligament fixation procedure?

a. May ultimately result in recurrent or de novo anterior compartment prolapse

b. May lead to hemorrhage due to laceration of vessels within the plexus of Santorini

c. Has a substantially higher anatomic success rate compared to uterosacral ligament suspension

d. Has a longer operating time and more prolonged recovery compared with abdominal sacrocolpopexy

43–21. Which of these statements regarding obliteration of the cul-de-sac of Douglas is correct?

a. These procedures are used to address cystoceles.

b. Both the Moschcowitz and Halban approaches may be associated with ureteral kinking and injury.

c. The transabdominal procedures are increasing in popularity due to their effective correction of apical prolapse.

d. McCall culdoplasty is preferred to uterosacral or sacrospinous ligament fixation for addressing significant vaginal apical prolapse.

43–22. All EXCEPT which of the following procedures are commonly performed concomitantly with a Lefort partial colpocleisis?

a. Cystoscopy

b. Perineorrhaphy

c. Vaginal hysterectomy

d. Anti-incontinence procedure

43–23. Lefort colpocleisis is contraindicated in which of the following patients?

a. Those with unexplained vaginal bleeding

b. Those without a normal, recent Pap smear

c. Those desiring future vaginal intercourse

d. All of the above

43–24. Which of the following statements regarding anal sphincteroplasty is correct?

a. Wound complications are rare.

b. Muscle fibers may be identified using a nerve stimulator.

c. Long-term continence rates to solid and liquid stool are excellent and approximate 80 percent.

d. Attention is primarily directed to repair of the external anal sphincter muscle to address the resting tone of the anal canal.

43–25. The patient with the defect below complains of passing flatus from her vagina and of occasional brown malodorous discharge sometimes when wiping after voiding. All EXCEPT which of the following are appropriate perioperative interventions?


Reproduced, with permission, from Corton MM: Anal incontinence and functional anorectal disorders. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 25-10.

a. Preoperative bowel preparation

b. Delaying defecation for several days postprocedure

c. Avoiding constipation with liberal use of stool softeners postprocedure

d. Antibiotic prophylaxis beginning 3 days before the reparative procedure

Chapter 43 ANSWER KEY