Urogynecology Practice Questions

Q: Sling operations include all except:

Le Fort repair. **Explanation:** The question asks to identify which procedure is **not** a sling operation. Sling operations are used to treat **nulliparous prolapse** or cases where the cervix needs to be preserved, by anchoring the cervix/isthmus to a fixed bony or ligamentous structure using synthetic or biological mesh. **1. Why Le Fort repair is the correct answer:** **Le Fort repair (Partial Colpocleisis)** is an **obliterative procedure**, not a sling operation. It involves denuding the anterior and posterior vaginal walls and suturing them together to close the vaginal canal. It is indicated for elderly women with advanced pelvic organ prolapse who are no longer sexually active and are medically unfit for major reconstructive surgery. **2. Analysis of Incorrect Options (Sling Operations):** * **Khanna’s Procedure:** A posterior sling operation where the cervix is attached to the **sacrospinous ligament** using a synthetic tape (Mersilene). * **Shirodkar’s Procedure:** An abdominal sling operation where the cervix is anchored to the **sacral promontory** (sacropexy) using a strip of fascia lata or synthetic material. * **Abdominocervicopexy:** A general term for abdominal sling procedures (like the Shirodkar or Purandare procedures) where the cervix is fixed to the abdominal wall or sacrum to provide support. **Clinical Pearls for NEET-PG:** * **Nulliparous Prolapse:** The treatment of choice is a sling operation to preserve fertility. * **Manchester Operation (Fothergill’s):** Indicated for mobile uterine prolapse with elongated cervix; it is *not* a sling operation but a reconstructive one involving shortening of Mackenrodt’s ligaments. * **Purandare’s Sling:** Anchors the cervix to the **rectus sheath** (anterior abdominal wall). * **Shout-out Fact:** Always check if the patient is sexually active before recommending Le Fort repair, as it permanently closes the vagina.

Q: What is the preferred surgical treatment for ureterovaginal fistula?

Ureteroneocystostomy. **Explanation:** Ureterovaginal fistula (UVF) most commonly occurs as a complication of radical pelvic surgeries (like Wertheim’s hysterectomy). The primary goal of management is to restore urinary continuity. **1. Why Ureteroneocystostomy is correct:** Most ureteric injuries leading to UVF occur in the **lower third** of the ureter, near the vesicoureteric junction. **Ureteroneocystostomy** (re-implantation of the ureter into the bladder) is the gold standard treatment because it provides a tension-free, definitive repair with a high success rate. If the ureter is too short to reach the bladder, techniques like a Psoas hitch or Boari flap are utilized to bridge the gap. **2. Why other options are incorrect:** * **End-to-end anastomosis (Ureteroureterostomy):** This is preferred for injuries in the **upper or middle third** of the ureter. In the lower third, the blood supply is often compromised, making anastomosis prone to strictures or breakdown compared to re-implantation. * **Ureteroileal conduit:** This is a form of urinary diversion used after total cystectomy (e.g., for bladder cancer). It is too invasive and unnecessary for a simple fistula repair. * **Implantation into the colon (Ureterosigmoidostomy):** This is an obsolete method of urinary diversion associated with high risks of metabolic acidosis, ascending infections, and late-onset malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of UVF:** Total Abdominal Hysterectomy (TAH). * **Diagnostic Test:** **Double Dye Test**. In UVF, the vaginal swab is soaked with clear urine (from the ureter) but not the dye (from the bladder). * **Gold Standard Investigation:** Intravenous Pyelogram (IVP) or CT Urogram to locate the site of injury. * **Initial Management:** If the fistula is small, a trial of conservative management with a **JJ stent** for 4–6 weeks may be attempted before surgery.

Q: Fothergill's repair is also known as:

Manchester operation. **Explanation:** **Fothergill’s repair**, also known as the **Manchester operation**, is a classic surgical procedure used for the management of **uterine prolapse**, specifically in women who wish to preserve their uterus (e.g., young patients or those avoiding hysterectomy) and where there is associated elongation of the cervix. The procedure involves three key steps: 1. **Dilation and Curettage (D&C):** To rule out any uterine pathology. 2. **Amputation of the elongated cervix:** To reduce the anatomical descent. 3. **Plication of the Mackenrodt’s (Cardinal) ligaments:** The ligaments are shortened and sutured to the anterior aspect of the remaining cervical stump. This provides structural support and pulls the cervix upwards and backwards, effectively anteverting the uterus. **Analysis of Incorrect Options:** * **Khanna’s sling operation:** A nulliparous prolapse repair using a synthetic sling (Mersilene tape) to suspend the uterus to the anterior abdominal wall. * **Le Fort’s repair:** A **colpocleisis** (obliterative) procedure used for total uterine prolapse in elderly women who are no longer sexually active. It involves denuding the vaginal walls and suturing them together. * **Shirodkar’s abdominal sling:** A procedure for uterine prolapse where the cervix is anchored to the sacral promontory using a strip of fascia lata or synthetic material. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** Fothergill’s repair should only be performed if the patient has completed her family, as cervical amputation increases the risk of **mid-trimester miscarriage** and **cervical dystocia** during labor. * **Ideal Candidate:** A woman with 2nd-degree prolapse and cervical elongation who desires uterine preservation. * **Key Ligament:** The **Mackenrodt’s ligament** is the primary support addressed in this surgery.

Q: Chassar Moir surgery is indicated for which of the following conditions?

Vesicovaginal fistula repair. **Explanation:** **Chassar Moir surgery** is a classic surgical technique used for the repair of a **Vesicovaginal Fistula (VVF)**. It is a vaginal approach (transvaginal) that utilizes the principle of "saucerization." In this procedure, the edges of the fistula are denuded and excised in a funnel shape, followed by a tension-free, layered closure. It is particularly effective for small to moderate-sized fistulae located in the mid-vaginal area. **Analysis of Options:** * **Option A (Uterine Inversion):** This is managed by the **Johnson’s maneuver** (manual replacement) or surgical methods like **O'Sullivan's** (hydrostatic), **Huntington’s**, or **Haultain’s** procedures. * **Option B (Vesicovaginal Fistula):** Correct. Chassar Moir is the standard vaginal repair. Other repairs include the **Latzko procedure** (partial colpocleisis for post-hysterectomy VVF) and the **O'Conor procedure** (transabdominal approach). * **Option C (Ureterovesical Fistula):** These usually require ureteric reimplantation into the bladder (**Ureteroneocystostomy**), such as the **Boari flap** or **Psoas hitch**. * **Option D (Retroverted Uterus):** Historically treated with "ventrosuspension" procedures like the **Gilliam’s surgery**, though rarely performed today. **NEET-PG Clinical Pearls:** * **Most common cause of VVF:** In developing countries, it is **obstructed labor**; in developed countries, it is **iatrogenic (post-hysterectomy)**. * **Gold Standard Investigation:** The **Three-swab test** (Moir’s test) is used to differentiate VVF from ureterovaginal fistula. * **Timing of Repair:** Traditionally, a wait of 3–6 months is advised after the injury to allow inflammation to subside, though "early repair" is gaining favor in non-radiated cases.

Q: Fistula formation due to the given etiology occurs within how much time?

5 days. ***5 days*** - **Obstructed labor** causes prolonged compression of the **bladder neck** and **anterior vaginal wall** between the fetal head and pubic symphysis, leading to **ischemic necrosis**. - The necrotic tissue **sloughs off within 5 days** after delivery, forming a **vesicovaginal fistula (VVF)** as the devitalized tissue separates. *24 hours* - **Ischemic changes** begin within hours, but complete **tissue necrosis** and sloughing requires more time to develop. - At 24 hours, tissues are still undergoing **ischemic damage** but have not yet progressed to complete necrosis and fistula formation. *48 hours* - While **tissue ischemia** is well-established by this time, **complete necrosis** and subsequent sloughing typically requires longer duration. - **Fistula formation** involves tissue breakdown and separation, which occurs after the necrotic tissue becomes completely devitalized. *2 weeks* - This timeframe is too long for **obstetric fistulas** caused by obstructed labor, which typically manifest within the first week. - **Surgical trauma-related fistulas** may present around this time, but **pressure necrosis fistulas** occur much earlier after delivery.

Question 1

Sling operations include all except:

Accepted Answer

Le Fort repair

Answer

Khanna procedure

Answer

Shirodkar procedure

Answer

Abdominocervicopexy

Question 2

A 38-year-old woman complains of chronic pelvic pressure. Further questioning reveals chronic lower back pain, constipation, difficulty in walking, and dyspareunia. Pelvic examination shows the uterine cervix lying low within the vaginal canal but not protruding through the introitus. What is the most likely diagnosis?

Accepted Answer

Uterine prolapse

Answer

Cystocele

Answer

Femoral hernia

Answer

Rectocele

Question 3

What is the preferred surgical treatment for ureterovaginal fistula?

Accepted Answer

Ureteroneocystostomy

Answer

End-to-end anastomosis with ureteric catheter support

Answer

Ureteroileal conduit

Answer

Implantation into the colon

Question 4

Which of the following does NOT provide support to the urethra and bladder neck?

Accepted Answer

Uterosacral Ligament

Answer

Pubourethral Ligaments

Answer

Arcus tendineus fascia

Answer

Levator ani muscles

Question 5

Fothergill's repair is also known as:

Accepted Answer

Manchester operation

Answer

Khanna's sling operation

Answer

Le Fort's repair

Answer

Shirodkar's abdominal sling operation

Question 6

A patient who underwent an extended hysterectomy one week ago presents with urine leakage from the vagina. She also experiences the urge to void periodically. What is the most likely cause of this presentation?

Accepted Answer

Ureterovaginal fistula

Answer

Vesico-vaginal fistula

Answer

Stress incontinence

Answer

Overflow incontinence

Question 7

Chassar Moir surgery is indicated for which of the following conditions?

Accepted Answer

Vesicovaginal fistula repair

Answer

Uterine inversion

Answer

Ureterovesical fistula repair

Answer

Retroverted uterus

Question 8

What is preserved in the Manchester operation?

Accepted Answer

Menstruation

Answer

Full length of cervix

Answer

Competency of os

Answer

Feility

Question 9

What is the recommended site for the placement of tension-free vaginal tapes for the management of stress urinary incontinence?

Accepted Answer

Middle part of the urethra

Answer

Ureterovaginal junction

Answer

Urethrovaginal junction

Answer

Upper part of the urethra

Question 10

Fistula formation due to the given etiology occurs within how much time?

Accepted Answer

5 days

Answer

24 hours

Answer

48 hours

Answer

2 weeks

Urogynecology — MCQs

Urogynecology — MCQs

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