Video Poster 1 WHERE I GO: BUILDING a MOBILEMEASURE FACTORS THAT APPLICATION SOCIO/ENVIRONMENTAL to AFFECT a WOMAN's DECISION to PEE

Wake Forest Baptist 1 . 1,2 ,G.Badlani 2 Wake Forest Baptist Health, Winston-Salem, NC ,J.Zambon 2 1,2 Volume 26, Number 10S, Supplement 1, October 2020 There are various approaches to surgical management of urethral A literature search was performed to assess current knowledge on 1 ,C.A.Matthews • Bladder and urethral mesh injuries are rare with a prevalence of <1% 1,2 Health, Winston-Salem, NC, endoscopic removal of urethral and bladder meshand injuries. edited Video from was a obtained bladder wall meshded extrusion into case the and proximal from a urethra/bladder case neck of that mesh embed- were managed in our department. of female pelvic mesh cases. Patients withurinary such tract injuries can symptoms including present with recurrent lower urinarybladder symptoms, tract hematuria, and infections, pelvic overactive pain. Surgery is mandatorymanagement. for Adequate proper inspection of the urethra andimportant bladder for preoperatively is proper surgical approach planning.laparoscopic/robotic, vaginal, The and decision endoscopic between approaches open, isthe usually location based and on extent of meshscopic exposure as removal well can as be surgeon appropriate experience. Endo- forproach patients possible requiring and the least for invasivecan ap- those utilize with sharp poor endoscopic instruments, tissue laserfor healing. transection, mesh and Endoscopic removal. We electrocautery present removal two cases demonstratingto endoscopic mesh approaches removal, one from the bladder side wallthra and / one bladder from the neck. proximal ure- Video Poster 2 ENDOSCOPIC REPAIR OF BLADDER ANDINJURIES URETHRAL MESH A. Plair Objective: Methods: Results: and bladder meshwide-spread injuries knowledge and with experience. Our the videothe viewer aims endoscopic to to the approach nature orient of having and urethralstrating and inform the appropriate bladder methods mesh for injuries least as endoscopic removal. well as demon- OSTER P ,C.L. 3 Univer- 4 IDEO University of V 1 . women pee was 4 ” s decision to void ’ ,H.L.Chang 3 Where “ ,L.C.An 3 ,M.A.Nowak 3 ” Female Pelvic Medicine & Reconstructive Surgery ,E.M.Hershey 3 Loyola University Chicago Stritch School of and up to four other commonly frequented sites 2 ,I.T.Moore ” 2 University of Michigan, Ann Arbor, MI, Where I Go. 3 “ home “ , W.Newhosue 3 Copyright © 2020 American Urogynecologic Society. Unauthorized reproduction of this article is prohibited. Copyright © 2020 American Urogynecologic Society. Unauthorized reproduction of this article Knowledge of factors that influence a woman Where I Go is a novel mobile app data collection tool that offers ,E.R.Mueller J. M. Miller: Nothing to disclose; E. R. Mueller: Nothing to disclose; 1 To describe the conceptualization, design, and build of a smartphone Over 45 investigators from the Prevention of Lower Urinary Tract www.fpmrs.net The current app prototype offers, eg 10+ demographics, repeated mea- ,J.Semerad 3 Carter sity of Michigan, Ann Arbor, MI Michigan, Ann Arbor, MI, Disclosures: I. T. Moore: Nothing to disclose; M.Nothing A. to Nowak: Nothing disclose; to C. disclose; L. H. Carter: L.disclose; Nothing Chang: W. Newhosue: to Renalis: disclose; Consultant; J. E. Semerad: M. NothingL. Hershey: to C. Nothing An: to Nothing disclose; to disclose. women opportunity to comprehensively report factorsif, influencing when, decisions why, about and where to pee (OTT Ref. No.: 2019-292). Medicine, Maywood, IL, identified as a central factor,Location thus labeling GPS capability for was incorporatedwas required into the for app. use, withuse. options The technical for design adding and location buildfor team labels Health from across the Communications days University Research of of Michigan (CHCR)dual app Center simultaneously platforms built (Android the and app IOS)ciples for to of: 1) maximize no inclusivity. more CHCR than appliedwoman six prin- to taps in self-initiate any app interaction interaction withnotifications the for (five app, in-the-moment times 2) per reports, ability day) of and(ecological for the 3) momentary reporting assessment. pushed on In look-back its periods designprocess of and build, 3-4 of we hours used early an and interactive frequentcommunity informal users feedback of from Where consortiumpeal members I and and Go. usability Effort ease wasI (Fig). prioritized Go, Early but towards the testing design application ap- involved can 48-hour extend use to of any Where number of days desired. Symptoms (PLUS) Research Consortium brainstormed and voted on the critical demographics and individual socio/environmental factors to be includedapp. in We eliminated the factors if equally well obtainedtronic by survey traditional paper or or by elec- necessity clinical exam. Variance in sures for 20+ factors potentially influencing a void decision,ticipant location at of each the interaction with par- the app (GPS markers ofamong latitude others. and longitude), Formal usability testing is completed,ported was in successful, and detail elsewhere, is as re- a separate abstract. mobile application named (plain language "pee") is important forclude promotion of location bladder and health. These access in- cleanliness, and to how women toilets, plan for autonomy andOther to manage factors urge include adaptive use sensations strategies in such the daily as life. anticipatingties, peeing toilet, opportuni- adjusting safety fluid intake, and andtechnologies avoiding is triggers. needed Development of to adequately innovative decision-making. measure these factors in the moment of S82 Conclusions: Results: Methods: Objective: Introduction: J. M. Miller Video Poster 1 WHERE I GO: BUILDING A MOBILEMEASURE FACTORS THAT APPLICATION SOCIO/ENVIRONMENTAL TO AFFECT A WOMAN'S DECISION TO PEE

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Conclusions: Due to the rare occurrence of bladder and urethral mesh injuries, 100 cc. The patient had an uncomplicated inpatient post-operative course and was knowledge pertaining to managing these injuries needs to be widely shared discharged on post-operative day 5. A 3-week follow-up voiding cystourethrogram within the pelvic reconstructive surgery community. Although endoscopic re- confirmed no frank extravasation prior to removal of her suprapubic and urethral pair is not the recommended surgical approach in many cases, it can offer an ap- catheters. Within the month following surgery, her serum creatinine level steadily im- propriate endoscopic approach for certain cases. proved to most recently 1.54 mg/dL. Additionally, she has had resolution of her both- Disclosures: A. Plair: Nothing to disclose; C. A. Matthews: Neomedic: Grant/ ersome urinary complaints and has had no urinary tract infections since her surgery. Research Support, Boston Scientific: Consultant and Grant/Research Support, Conclusions: Augmentation cystoplasty, although invasive, is a safe and effec- Johnson and Johnson: Expert witness; J. Zambon: Nothing to disclose; G. tive procedure for neurogenic bladder patients with storage symptoms related to Badlani: Nothing to disclose. decreased bladder capacity, poor compliance, and/or symptomatic detrusor over activity who have failed other conservative and less invasive measures. Disclosures: T. Tam: Nothing to disclose; A. Mahdy: Nothing to disclose. Video Poster 3 DUPLICATED COLLECTING SYSTEM Video Poster 5 E. S. Chang1,R.J.Hidalgo1, L. R. Wiegand2, A. M. Wyman1. 1University of 2 LONGITUDINALVAGINAL SEPTUM RESECTION VIA South Florida, Tampa, FL, University of South Florida, Tampa, FL HANDHELD VESSEL SEALER AND TISSUE DIVIDER Objective: The objectives of this video is to discuss the presentation, evaluation, and treatment of duplicated urinary collecting systems, and to present a Z. S. Cope. University of Louisville, Louisville, KY, S. L. Francis. University of case of duplicated collecting system with ectopic ureteral implantation at the Louisville, Louisville, KY, O. Cardenas-Trowers. University of Louisville, vaginal introitus. Louisville, KY,andA. Gupta. University of Louisville, Louisville, KY Methods: We present the case of a 56 year-old female presenting with a history Objective: To present, via video, resection of a vaginal septum with a handheld of recurrent urinary tract infections starting in adolescence. She reported symp- vessel sealer and tissue divider. toms of urinary urgency, frequency, and incontinence. She additionally reported Methods: An 18-year-old female with uterine didelphis, bicollis and symptom- an unclear history of an incidental diagnosis of ureteral anomaly in childhood. atic longitudinal vaginal septum presented for surgical management. We de- For evaluation, a computed tomography urogram was performed, which revealed scribe our technique for resection of the septum using a hand-held vessel a right duplicated kidney with upper ureter inserting into the bladder neck, and sealer and tissue divider with minimal blood loss. After excision of the septum lower ureter with unclear course. Avoiding cystogram was performed to evaluate the vaginal edges were reapproximated with absorbable suture. for ureteral reflux which was not demonstrated. A renal MAG3 scan was per- Results: Video Presentation (please see clinical relevance) formed and demonstrated differential function between the two right renal moi- Conclusions: Video Presentation (Please see clinical relevance) eties but no evidence of obstruction to the outflow tract to either renal moiety. Clinical Relevance: A lateral fusion defect of the Mullerian ducts can present Exam under anesthesia, cystoscopy, and right retrograde pyelogram revealed with varying presentations of an isolated longitudinal vaginal septum or an ectopic ureteral orifice at the vaginal introitus and mild hydroureter leading to the upper renal moiety. Results: Complete mapping of this patient's right duplicated collecting system revealed the lower renal moiety drained by a normal ureter leading to an orthotopic ureteral orifice and the upper renal moiety draining into a mildly dilated ureter leading to an ectopic ureteral orifice at the vaginal introitus. The patient will subsequently undergo robotic-assisted right ureteroureterostomy and excision of distal ectopic ureter in a combined laparoscopic and vaginal approach. Conclusions: Duplicated urinary collecting systems are the most com- mon birth defect related to the urinary tract and can be frequently encountered by the pelvic surgeon. Knowledge of the presentation and workup of suspected duplicated collecting system is important in determining appropriate treatment. Disclosures: E. S. Chang: Nothing to disclose; R. J. Hidalgo: Nothing to disclose; L. R. Wiegand: Nothing to disclose; A. M. Wyman: Nothing to disclose.

Video Poster 4 FIGURE 1. SURGICAL TECHNIQUE OF AUGMENTATION CYSTOPLASTY Vaginal Septum prior to resection with handheld vessel sealer and tissue divider T. Tam. TriHealth - Good Samaritan Hospital, Cincinnati, OH and A. Mahdy. University of Cincinnati, Cincinnati, OH Objective: Augmentation cystoplasty is a known procedure for neurogenic bladder with storage symptoms refractory to other less invasive measures. Our objective is to present our technique and outcome of a case with neurogenic bladder. Methods: We present a 53-year-old female with a history of neurogenic bladder. She had been performing clean intermittent self-catheterization for many years without issue however had complaints of urinary incontinence in between catheterization and recurrent urinary tract infections. The patient had tried multiple anti-cholinergic medications, onabotulinumtoxinA injections in the bladder as well as InterStimTM therapy without alleviation of her symptoms. Her blood work confirmed worsening renal function with a steadily rising serum creatinine level, which was now 2.44 mg/dL, and worsening hydronephrosis on renal ultrasound. Video urodynamic evaluation demonstrated vesicoureteral efflux and poor bladder compliance. The clinical indications and goals of the bladder augmentation were to decrease urinary incontinence, urinary tract infections, as well as improve bladder compliance and alleviate the vesicoureteral efflux with resulting improvement of renal function. The video was completed 4 months after her procedure was performed. Results: The patient successfully underwent an augmentation cystoplasty. The FIGURE 2. Anterior vagina after removal resection of vaginal septum total operating time was 2 hours and 30 minutes with an estimated blood loss of with handheld vessel sealer and tissue divider

Copyright © 2020 American Urogynecologic Society. Unauthorized reproduction of this article is prohibited. Abstracts Female Pelvic Medicine & Reconstructive Surgery • Volume 26, Number 10S, Supplement 1, October 2020

concomitantly with uterine and/or cervical anomalies. Patients often present Disclosures: J. Shaw: Nothing to disclose; K. Strohbehn: Nothing to disclose; L. during adolescence with chief concerns of pain and difficulty inserting tampons Wilson: Nothing to disclose. and dyspareunia. As the physical exam is often limited by patient anxiety and discomfort, further elucidation of the extent of the anomaly(ies) mandates imaging, most often via transabdominal or transperineal ultrasound or mag- netic resonance imaging; as transvaginal imaging is often not tolerated. Sur- Video Poster 8 gical management should be directed towards patient goals and can be ROBOTIC ASSISTED LAPAROSCOPIC FEMALE AUS completed via a hysteroscopic approach or clamp and transection which can (ARTIFICIAL URINARY SPHINCTER) REVISION be associated with increased blood loss. We present the use of a handheld vessel N. Hernandez1,N.Abdullah2, C. Tallman1,R.Khavari1. 1Houston Methodist sealer and tissue divider used to efficiently resect a longitudinal vaginal septum Hospital, Houston, TX, 2Texas A&M College of Medicine, Houston, TX with minimal blood loss. Objective: Robotic assisted laparoscopic placement of Artificial Urinary Disclosures: Z. S. Cope: Nothing to disclose; S. L. Francis: Nothing to disclose; Sphincter (AUS) for women suffering of urinary incontinence has been de- O. Cardenas-Trowers: AMAG Pharrmaceuticals: Grant/Research Support; A. scribed as a feasible procedure. We report our experience in a robotic assisted Gupta: Nothing to disclose. laparoscopic AUS revision using an Ohm meter. A 24-year-old female with history of low lumbar myelomeningocele presenting with stress urinary incontinence (SUI) and neurogenic detrusor overactivity. The patient is highly active and desired improvement of her SUI to allow her to participate in weight lifting competitions without a pad and in the appropriate attire. She has been on Video Poster 6 self-catheterization and intradetrusor injection of onabotulinumtoxinA. Conser- SINGLE-INCISION PUBOVAGINAL SLING WITH FASCIA LATA vative SUI management such as repeated injection of urethral bulking had AUTOGRAFT failed. Therefore, she underwent robotic placement of a 7-cm bladder neck 1 1 2 1 1 P.A. Samimi , J. Panza ,S.M.Hartigan ,R.A.Adam . Vanderbilt University AUS AMS 800, and had an uneventful recovery. Simply having the cuff around 2 Medical Center, Nashville, TN, Vanderbilt University Medical Center, Nashville, TN the bladder neck provided complete continence without the need to activate the Objective: A pubovaginal sling with autograft is performed with harvest of the AUS. However, three years later she presented with significant return of incon- fascia lata or the rectus fascia, which is often tensioned from an abdominal ap- tinence and on exam her AUS was not cycling well. Cystoscopy did not show proach. The objective of this video is to demonstrate a transvaginal technique erosion. No vaginal extrusion was observed. for pubovaginal sling which avoids the use of an abdominal incision or graft. Methods: Using a small low suprapubic incision, the AUS tubing was ex- We demonstrate this technique using a transvaginal suture capturing device posed. The tubing was transected and fluid was aspirated from the pressure bal- and a fascial stripper, avoiding a more invasive approach and minimizing the loon to evaluate for fluid loss. The Ohm-meter leads were applied at the level of breadth of complications associated with an abdominal incision. the skin and around the injection needle used to flush fluid through the tubbing Methods: The patient is a 76-year-old woman who presented with recurrent to the cuff, pump and pressure balloon, with evidence of high resistance at the stress urinary incontinence after failure of both a retropubic and transobturator cuff tubing, identifying a leak at this level. midurethral mesh sling. Her surgical history is also significant for sacrocolpopexy Results: Robotic assisted laparoscopic removal and replacement of all with mesh and hernia repair. In the right lateral decubitus position, the fascia lata components of an AUS AMS 800 with a 7-cm bladder neck cuff was per- was harvested with a fascial stripper device through a small (1.5 cm) leg incision. formed. Urethral foley catheter was removed the next day. Patient is 4 months She was then repositioned to dorsal lithotomy position. Utilizing an inverse U- post procedure and is completely dry and performing self-catheterization with incision, a vaginal incision was made and dissection of the periurethral space AUS not activated. with entry into the retropubic space performed. The autograft was then attached Conclusions: Robotic assisted laparoscopic removal and replacement of a to Cooper’s ligament through this dissection with the aid of the transvaginal su- bladder neck AUS is feasible and safe. For non-functioning AUS where there ture capturing device and tensioned into place from the vaginal aspect. is suspicion of a break in the system, the Ohm-meter is a valuable tool that Results: The patient had no peri-operative complications. After several months can assist in intraoperative decision making. of follow-up, she reports significant improvement in her symptoms and is satis- Disclosures: N. Hernandez: Nothing to disclose; N. Abdullah: Nothing to fied with her outcome. disclose; C. Tallman: Nothing to disclose; R. Khavari: Nothing to disclose. Conclusions: With the use of a transvaginal suture capturing device and fascial stripper, a pubovaginal sling can be effectively performed without an abdominal incision and its associated complications. As the use of mesh becomes more re- stricted, there remains a need for continued support and development of minimally invasive tools in the treatment of stress urinary incontinence. Video Poster 9 Disclosures: P.A. Samimi: Nothing to disclose; J. Panza: Nothing to disclose; S. FPMRS VIDEO TELEMEDICINE VISIT IN THE TIME OF M. Hartigan: Nothing to disclose; R. A. Adam: Nothing to disclose. COVID-19 N. D. Metcalfe1,G.M.Northington2, R. S. Kelley1. 1Emory University School of Medicine, Atlanta, GA, 2Emory University School of Medicine, Atlanta, GA Objective: During the COVID-19 pandemic, alternative forms of delivering health care such as telemedicine have received considerable attention. Pelvic Video Poster 7 floor disorders tend to be more prevalent and disabling in older patients with AUTOLOGOUS FASCIA LATA USE FOR COMBINED SACRAL multiple medical co-morbidities, putting them at higher risk of COVID-19 com- COLPOPEXY AND RECTOPEXY plications. Fortunately, telemedicine is a unique health care option that minimizes J. Shaw. Dartmouth Hitchcock Medical Center, The Geisel School of Medicine exposure to COVID-19 while providing patients with specialized, high-quality at Dartmouth, Lebanon, NH, K. Strohbehn. Dartmouth-Hitchcock Medical medical care and improvement of quality of life. Given video telemedicine may Center, Lebanon, NH and L. Wilson. Dartmouth Hitchcock Medical Center, be a new experience for many patients and providers, we present our recommen- TheGeiselSchoolofMedicineatDartmouth,Lebanon,NH dations for creating a successful and positive experience. Objective: Propose use of autologous fascia lata for combined rectopexy Methods: We will review our FPMRS Division’s recommendations for opti- and sacrocolpopexy, with or without resection, and present a video of mizing telemedicine platforms, information security/privacy, patient selection, our technique. appointment workflow, appointment location, lighting, physician attire, physi- Methods: Video presentation includes demonstration of minimally-invasive cian mannerisms, appointment audio, appointment rehearsals, and feedback fascia lata harvest using fascial strippers and technique of fixation of fascial evaluations. graft which optimizes tissue integrity and tensile strength. Results: There are many available video telemedicine platforms – it is impor- Results: Demonstration of a feasible and safe autologous alternative to tant to find a platform that adheres to HIPAA and BAA privacy standards and mesh per patient preference or in setting of resection rectopexy at time to enable additional security settings to better protect patient information (Chen of sacrocolpopexy. BX, 2020). Given telemedicine is new for many providers and staff, creating a Conclusions: This approach may be considered by both FPMRS and colorec- patient selection algorithm, and a detailed pre-appointment and day-of-visit tal surgeons for a combined approach. workflow can help clarify and standardize the process for everyone. Subjective

Copyright © 2020 American Urogynecologic Society. Unauthorized reproduction of this article is prohibited. Female Pelvic Medicine & Reconstructive Surgery • Volume 26, Number 10S, Supplement 1, October 2020 Abstracts

and objective patient medical information (ie intake forms, validated question- Results: An excellent anatomic result was achieved without placing mesh in naires, voiding diaries, vital signs obtained with home monitors, and outside proximity to the colon. medical records) provided by the patient prior to the visit can augment the pa- Conclusions: Minimally invasive sacrocolpopexy is widely used for apical tient evaluation and increase appointment efficiency. Specific video and audio prolapse with an excellent success rate and an acceptable complication rate; how- settings can optimize the telemedicine appointment for both the provider and ever, certain contraindications exist including cardiopulmonary compromise that patient. We recommend finding a private location without distractions or back- make preclude steep Trendelenburg position, extensive pelvic adhesions, and con- ground noise (Lasky J, 2020). If an ideal location is not available, then we rec- ditions such as diverticulitis, which make it inadvisable to place permanent mesh ommend a simple virtual backdrop (Calloway B, 2020). Additionally, we in close proximity to the colon.1 For patients in the latter category, the use of bio- recommend looking your best and wearing darker professional clothing in order logic materials is an option but the reported success rates are lower compared with to increase the contrast (Lasky J, 2020). Furthermore, positioning your light mesh.2 Laparoscopic pectopexy is a new operation developed by Dr. GK Noé for source in-front or beside the webcam can reduce facial shadows and reflections obese patients, in whom sacrocolpopexy can be challenging.3 This technique (Lasky J, 2020). Remember to be speak slowly and clearly with appropriate in- produced outcomes equivalent to sacrocolpopexy in an RCT, with fewer bowel tonation, while being cognizant of your facial expressions, body-language, eye- complications.4,5 The video shows how the technique was successfully applied contact, and mannerisms (Calloway B, 2020 and Lasky J, 2020). Finally, we to a patient with a history of recurrent diverticulitis who had previously been un- strongly recommend rehearsing prior to the first appointment (Calloway B, successfully treated with a sacrocolpopexy using a biologic graft. 2020) and requesting feedback from your patients, staff, and providers after each References: appointment in order to identify and resolve any issues that may arise. The 1. Ganatra AM, Rozet F, Sanchez-Salas R, et al. The current status of lapa- feedback we have received for our video telemedicine visits have been overall roscopic sacrocolpopexy: a review. Eur Urol. 2009;55(5):1089-1103. positive with high patient satisfaction rates (Emory Clinic Patient Satisfaction 2. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Comments, 2020). Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. Conclusions: By offering telemedicine appointments to patients with pelvic 2016;10:CD012376. floor disorders, we provide them with specialized, high-quality medical care 3. Banerjee C, Noé KG. Laparoscopic pectopexy: a new technique of pro- and improvement of quality of life – all while reducing the burden on emer- lapse surgery for obese patients. Arch Gynecol Obstet. 2011;284(3):631-635. gency rooms and urgent care centers and limiting exposure to COVID-19. 4. Noé KG, Schiermeier S, Alkatout I, Anapolski M. Laparoscopic Disclosures: N. D. Metcalfe: Nothing to disclose; G. M. Northington: Nothing pectopexy: a prospective, randomized, comparative clinical trial of standard laparo- to disclose; R. S. Kelley: Nothing to disclose. scopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study. J Endourol. 2015; 29(2):210-215. 5. Noé GK, Schiermeier S, Papathemelis T, et al. Prospective international Video Poster 10 multicenter pectopexy trial: Interim results and findings post surgery. Eur J REMOVAL OF VAGINAL FOREIGN BODY RETAINED Obstet Gynecol Reprod Biol. 2020;244:81-86. FOR 13 YEARS Disclosures: J. Heusinkveld: Nothing to disclose; V. Winget: Nothing to dis- E. Plasencia, J. Heft, E. E. Weber LeBrun. University of Florida College of close; M. G. Gabra: Nothing to disclose; I. B. Addis: Nothing to disclose; K. Medicine, Gainesville, FL D. Hatch: Nothing to disclose. Objective: Foreign bodies in the vagina, although rare in adult women, can lead to significant morbidity. Vaginal foreign bodies can cause pain, infection, infertility, peritonitis, fistula-formation, sepsis, and even chronic inflammation thought to cause malignancy. Methods: We present the case of a 31-year-old gravida 0 with a vaginal Video Poster 12 retained foreign body that had been in place for thirteen years. She presented VESICOVAGINAL FISTULA REPAIR AT TIME OF with a history of pelvic pain for many years. Her history was notable for never COLPOCLEISIS being sexually active and remote history of tampon use. On exam, an obstruc- B. Roberts1,E.S.Chang2,R.J.Hidalgo2, L. R. Wiegand3, A. M. Wyman2. tion in the upper part of the vagina was seen. MRI showed a 5.0 x 2.0 cm tu- 1University of South Florida, Tampa, FL, 2University of South Florida, Tampa, bular foreign body positioned obliquely within the endocervical canal and FL, 3University of South Florida, Tampa, FL upper vagina with surrounding fluid. Objective: The objectives of this video are to discuss the presentation, evalua- Results: Patient was taken to the operating room for exam under anesthesia and tion, and surgical management of a patient with a large vesicovaginal fistula at removal of foreign body. Exam confirmed near-complete obliteration of the vag- the time of colpocleisis. inal canal due to circumferential vaginal stenosis. Cystoscopy showed a dupli- Methods: We present the case of an 83 year-old female with a history of stage cated ureter on the left side. A vertical incision was made with a long knife IV prolapse who underwent initial treatment with placement of a pessary. After blade through the dense apical scar. Purulent material was expelled and the for- a year following pessary placement, the patient had the device removed and eign body was identified. The entirety of the tampon applicator was carefully re- urine was noted to be in the vaginal vault, highly suspicious for a vesicovaginal moved. Vaginoscopy confirmed there were no other portions of the specimen fistula. Subsequently, the patient had a cystourethrogram confirming a 0.7 x remaining. Once open, the vaginal canal measured 15cm from hymen to cervix. 1 cm vesicovaginal fistula. For further evaluation and surgical planning, the pa- Conclusions: Retained foreign bodies in the vagina require prompt treatment tient underwent an exam under anesthesia and cystourethroscopy. On vaginal with imaging and removal in the operating room as needed. Undiagnosed exam, the patient was noted to have stage IV prolapse with a large 5 cm Mullerian anomalies could predispose patients to long-term retention or com- vesicovaginal fistula with the ureters clearly visible, approximately 3 cm from plex removal. the opening of the fistula. Following evaluation, the patient decided to proceed Disclosures: E. Plasencia: Nothing to disclose; J. Heft: Nothing to disclose; with definitive surgical management. E. E. Weber LeBrun: Nothing to disclose. Results: The patient underwent a vesicovaginal fistula repair with concomitant colpocleisis. The case was performed by Urology and Urogynecology in order to preserve ureteral integrity. At the patient's one month follow up, she had no complaints of prolapse or vaginal leaking. She additionally underwent a Video Poster 11 cystourogram demonstrating no leakage at the site of repair. PECTOPEXY: AN ALTERNATIVE TO SACROCOLPOPEXY Conclusions: Neglect of a vaginal pessary can lead to serious complications J. Heusinkveld1, V.Winget1,M.G.Gabra1,I.B.Addis2,K.D.Hatch3. 1Uni- indicating the importance of patient education and careful follow-up. Surgical versity of Arizona, Tucson, AZ, 2The University of Arizona, Tucson, AZ, 3Uni- planning is a key component in effectively managing a vesicovaginal fistula with ure- versity of Arizona, Tucson, AZ teral presentation in order to preserve ureteral integrity. Concomitant vesicovaginal Objective: To demonstrate how a new technique for apical suspension can be repair and colpocleisis can be performed safely with effective cure of a vesicovaginal used in patients with contraindications to mesh sacrocolpopexy fistula and stage IV prolapse. Methods: A patient in whom mesh sacrocolpopexy was contraindicated due to Disclosures: B. Roberts: Nothing to disclose; E. S. Chang: Nothing to disclose; recurrent diverticulitis was treated with pectopexy. The procedure was recorded R. J. Hidalgo: Nothing to disclose; L. R. Wiegand: Nothing to disclose; A. M. for educational purposes with the patient's consent and edited for presentation. Wyman: Nothing to disclose.

close to the urethra. Eroded polypropylene mesh is a nidus for stone formation, Video Poster 13 and as such causes recurrent infections, inflammation, and other sequelae. A tra- SURGICAL MANAGEMENT OF RETROPUBIC SLING ditional more invasive excision approach involves vaginal incision with inten- BLADDER EROSION tional urethrotomy. Less invasive cystoscopic options include holmium laser, H. Chapman. Creighton University School of Medicine, Phoenix, AZ, loop electrode, and sharp excision with scissors. Cystoscopic approaches have D. E. Stone, III. Valley Urogynecology Associates, Phoenix, AZ less morbidity for the patient, however this comes with lower success rates Objective: In this video, we will review the etiology and diagnosis of a case of and possible need of reoperation. We demonstrate one method of transurethral sling erosion into the bladder and subsequent surgical management. mesh excision with scissors and discuss tips and pitfalls of this procedure. Methods: The patient in this video had undergone a retropubic mid-urethral Methods: We present the case of a 40-year-old female with a history of com- sling in 2004. She reportedly recovered well and had no issues until 2016 when plicated vaginal birth 15 years prior. Postpartum, she had a Foley catheter in she developed severe bladder pain and recurrent urinary tract infections. Further place for 2 days. Upon removal she complained of continuous urine leakage. workup revealed bladder stones attached to the eroded sling mesh. Management A TVT sling was placed eight weeks postpartum with resolution of her symp- included repeated stone removal and mesh cauterization. In 2019, she was sent toms. She presented to us with a history of recurrent UTI, intermittent hematu- to our clinic for findings of recurrent stones and mesh erosion along the right ria, and a feeling of incomplete emptying. During an in office straight anterior bladder wall. catheterization, a partial obstruction was encountered within the urethra along Results: We review the surgical technique for a robotic assisted laparoscopic with an elevated PVR of 265 mL. She underwent cystoscopic excision of eroded resection of a retropubic mid-urethral sling, a portion of which had eroded into polypropylene mesh with embedded urethral calculi. More robust semi-rigid the anterior bladder wall. In this case, the mesh was identified in a more lateral scissors were used in place of flexible stem scissors, allowing for significantly and cephalad position than where we would typically expect. After identifica- easier removal. tion of the mesh, the dissection was carried out until it reached the bladder wall. Results: The patient was discharged with a Foley catheter that was removed af- As anticipated, a cystotomy was developed at the point of mesh erosion. Follow- ter 7 days without issue. Postoperatively, she denied hematuria and reported res- ing identification of the area of mesh erosion, the mesh was further dissected un- olution of all of her symptoms. Office PVR was 40 mL. til reaching the endopelvic fascia. The mesh was excised and sent for pathologic Conclusions: Intraurethral excision of eroded polypropylene mesh with scis- review. The cystotomy was repaired and the retropubic space closed. sors is a less invasive option that can be considered prior to transvaginal excision Conclusions: This video shows that a retropubic sling removal can be safely with urethrotomy. We recommend checking preoperatively that appropriate and easily performed with laparoscopy. It also shows that a retropubic sling scissors that will be able to cut through polypropylene are available. can be found in a more lateral and superior area than where it is typically encountered in the retropubic space. We hypothesize that this misplacement may have been a risk factor for the development of mesh erosion. Disclosures: H. Chapman: Nothing to disclose; D. E. Stone III: Nothing to disclose.

Video Poster 14 RECTOVAGINAL FISTULA REPAIR WITH CONCURRENT LEFORT COLPOCLEISIS B. Gaigbe-Togbe1,L.Dabney2, C. Paka1,A.Hardart2. 1Icahn School of Med- icine at Mount Sinai, New York, NY, 2Mount Sinai West/Mount Sinai Morningside, New York, NY Objective: Rectovaginal fistula is a rare complication from the use of a pessary for pelvic organ prolapse management. In this video we present the concurrent repair of a rectovaginal fistula, uterovaginal prolapse with concurrent LeFort colpocleisis, and occult stress urinary incontinence with midurethral sling placement. Methods: This is a case of an 83-year-old P2002 with a longstanding history of FIGURE 1. Intraurethral eroded TVT mesh with calculi. stage 4 uterovaginal prolapse. Patient had a history of urinary retention with unreduced prolapse resulting in urosepsis. She initially declined surgical repair and was managed with a 2 ¾ Gellhorn pessary. The patient was lost to follow-up Disclosures: S. Spector: Nothing to disclose; S. T. Mama: Nothing to disclose. for 18 months and presented in the setting of an admission for retinal artery oc- clusion and embolic stroke where she was noted to have fecal incontinence. Fur- ther evaluation revealed a 3 cm rectovaginal fistula due to the neglected Gellhorn pessary. The patient was counseled and subsequently underwent a concurrent rectovaginal fistula repair, LeFort colpocleisis for uterovaginal prolapse, Video Poster 16 and midurethral retropubic sling for occult stress urinary incontinence. DECISION MAKING IN VESICOVAGINAL FISTULA REPAIR: Results: The procedure was uncomplicated, and the patient reported successful A CASE WALKTHROUGH resolution of her symptoms at 2 months postoperatively. S. Spector. FPMRS, Cooper University Hospital, Camden, NJ L. Lipetskaia. Conclusions: Concurrent rectovaginal fistula repair with LeFort colpocleisis Cooper University Hospital, Camden, NJ and midurethral sling placement is a viable treatment option versus a staged re- Objective: To walkthrough the decision-making process when approaching pair of rectovaginal fistula with subsequent treatment of stage 4 prolapse. vesicovaginal fistula repair as demonstrated in a patient that underwent Disclosures: B. Gaigbe-Togbe: Nothing to disclose; L. Dabney: Nothing to dis- robotic-assisted repair. close; C. Paka: Nothing to disclose; A. Hardart: Nothing to disclose. Methods: A 43-year-old female patient presented with a new vesicovaginal fistula. She had a recent history of open abdominal hysterectomy complicated by dense adhesions and postoperative diagnosis of posterior wall bladder rupture. Video Poster 15 She underwent an open bladder repair 9 days after her hysterectomy; 1 week TRANSURETHRAL EXCISION OF ERODED URETHRAL TVT thereafter she was diagnosed with a vesicovaginal fistula. Eight weeks of con- MESH: A DISCUSSION AND CASE REPORT servative management with Foley catheter was attempted but failed. We per- S. Spector. Cooper University Hospital, Camden, NJ S. T. Mama. Cooper formed a robotic-assisted vesicovaginal fistula repair. Medical School of Rowan University, Moorestown, NJ During the surgery, multiple decision-making points were encountered and Objective: Urethral erosion of polypropylene mesh is a rare complication of resolved through analysis of the risks and benefits. The key decisions included the transvaginal tape procedure (TVT). In terms of surgical causes, it is thought are: (1) how to decide between a vaginal approach, robotic approach, open ab- to be caused by excessive tensioning of the mesh or dissection in a plane too dominal approach, or variants thereof; (2) if and when to stent the ureters; (3)

how to approach the fistula dissection and whether an intentional cystotomy can inflammation, risk of injury to vital structures such as major vessels, bowel be avoided; (4) how to decide between options for flap or barrier placement. or bladder, as well as preservation of pelvic floor support after mesh removal. Results: Postoperative retrograde cystogram demonstrated no extravasation. We present a series of three patients with recurrent pain and infectious compli- The patient remains without signs or symptoms of recurrence at four months. cation after sacrocolpopexy that each underwent robotic assisted laparoscopic Conclusions: This video demonstrates the systematic thought process in- mesh excision and concomitant uterosacral ligament suspension. volved when approaching vesicovaginal fistula repair. These same decisions Methods: Three patients (ages 51-59) underwent robot assisted removal of will have to be made as surgeons encounter similar cases. sacrocolpopexy mesh and uterosacral ligament suspension at an academic Disclosures: S. Spector: Nothing to disclose; L. Lipetskaia: Nothing to disclose. tertiary care hospital with a single surgeon. Patient charts and surgical videos were reviewed. Results: Mean operative time was 129 minutes. Mean estimated blood loss was Video Poster 17 66 mL. No complications were reported. At mean follow up of 2.5 months all A SIMPLIFIED APPROACH TO LAPAROSCOPIC three patients report improvement in the pain that was the indication for their SACROHYSTEROPEXY: A MINIMALLY INVASIVE PROLAPSE mesh excision. No patient has recurrence of prolapse. REPAIR SURGICALVIDEO Conclusions: This video demonstrates the critical steps of robot assisted laparoscopic sacrocolpopexy mesh excision and concomitant uterosacral ligament V. W i n g e t 1,M.G.Gabra2,I.B.Addis3,K.D.Hatch4,J.Heusinkveld1. 1Univer- suspension. Excellent visualization of the mesh and vital structures as well as sity of Arizona, Tucson, AZ, 2University of Minnesota, Minneapolis, MN, 3The reduced morbidity over open surgery are advantages of a robotic approach. Con- University of Arizona, Tucson, AZ, 4University of Arizona, Tucson, AZ comitant uterosacral ligament suspension is both safe and feasible, and excellent Objective: To illustrate a modified technique for mesh laparoscopic sacrohys- visualization of the ureters may reduce complications with this approach. teropexy for pelvic organ prolapse in a postmenopausal woman who desired Uterosacral ligament suspension provides a mesh free option for reducing pro- uterine preservation. lapse recurrence in patients that require surgical intervention for a mesh related Methods: A 64 year old postmenopausal Gravida 5 Para 4014 with Stage 2 complication. prolapse with anterior leading edge presented with two years of vaginal bulge Disclosures: L. Jones: Nothing to disclose; J. Slawin: Nothing to disclose; N. symptoms. She was consented for videotaping of her surgical procedure preop- Rosenblum: Nothing to disclose. eratively as part of her informed consent process. She underwent a laparoscopic mesh sacrohysteropexy on January 24, 2020. The procedure was recorded, edited and narrated for educational purposes. Results: A significant percentage of women seeking treatment for pelvic organ prolapse, noted to be between 20-46 percent in the literature, express a desire to Video Poster 19 preserve their uterus (Korbly et al, 2013) Some patients wish to retain their ROBOTIC REVISION OF SACRAL COLPOPEXY uterus for cultural reasons or to preserve fertility, while others desire preserva- A. Holubyeva1, K. M. Nicholson1, P. S. Finamore2,D.L.O'Shaughnessy2. tion of sexual function (Ridgeway, 2015). 1 2 Uterine preserving techniques yield minimal blood loss, shorter recovery Northwell Health System Southside Hospital, Bay Shore, NY, Donald and times and maintain natural pelvic anatomy when compared with repair involving Barbara Zucker School of Medicine at Hofstra/Northwell, Bay Shore, NY hysterectomy (Meriwether et al., 2018). Historically, sacrohysteropexy involved Objective: The objective of this video is to demonstrate the technique of per- attaching mesh from the posterior cervix to the sacral promontory, however this forming a revision of a sacral colpopexy using robotic assistance in a patient approach significantly limited the ability to correct anterior wall prolapse. with recurrent prolapse secondary to the detachment of the Y-mesh from the sa- Currently, most sacrohysteropexy cases involve attaching mesh to the ante- cral promontory. rior cervix and upper vaginal wall, tunneling through the broad ligament, fixing Methods: The patient is a 61-year-old with a past medical history of diabetes, the mesh to the posterior cervix and then to the sacral promontory. Compared to hypertension, fibroids, and stress urinary incontinence. On urogynecologic ex- the prior techniques with posterior cervical attachment of mesh, these approaches amination she was found to have stage III uterovaginal prolapse. She underwent allow for correction of anterior prolapse (Kalis et al., 2019) (Jan et al., 2018). The a robotic assisted supracervical hysterectomy, bilateral salpingectomy, sacral vascular supply via the utero-ovarian vessels is compromised in many cases by colpopexy and midurethral sling. At her 5-month follow-up, the patient dissection and tunneling through the broad ligament (Kupelian et al., complained of worsening vaginal bulge symptoms and urge incontinence. 2016) ( Serdinšek et al 2019). She was found to have pelvic organ prolapse recurrence. The patient was Conclusions: This operative video demonstrates a modification on the mesh counselled on surgical as well as non-surgical treatment options and decided sacrohysteropexy that simplifies the procedure and has potential to reduce oper- to undergo a robotic revision of the sacral colpopexy. ative time for women that do not desire fertility. In contrast to traditional mesh During the revision procedure, it was noticed that the mesh was dislodged sacrohysteropexy, this procedure eliminates the need to tunnel through the from its original point of attachment to the sacral promontory, but remained ad- broad ligament. The broad ligament is instead dissected bilaterally to the level equately attached to the vagina and cervix. An incision was made overlying the of the cardinal ligaments; the uterus is completely separated from the ovarian sacral promontory and the peritoneum was dissected to expose the anterior lon- pedicle. The round ligament and ovarian collateral vessels are sacrificed without gitudinal ligament. Further dissection uncovered the three previously placed compromising the perfusion to the uterus due to the uterine artery collateral ves- permanent sutures still attached to the ligament, with no mesh attached. These sels that provide the majority of the vascular supply to the uterus. Then the mesh sutures were removed and the sacral tail of the Y mesh reattached to the anterior arms can be wrapped around the cervix, fixed posteriorly and attached to the an- longitudinal ligament with three interrupted permanent sutures. Avaginal exam terior spinal ligament at the sacral promontory. The need to tunnel through the revealed excellent suspension and support. There was no evidence of bladder or broad ligament, with its attendant risk of injury to the uterine vessels, is thus ureteral injury upon cystoscopy at the conclusion of the case. eliminated. Results: Following her mesh revision surgery, our patient had an uncompli- Disclosures: V.Winget: Nothing to disclose; M. G. Gabra: Nothing to disclose; cated post-operative course. Upon further office follow up at 6 months, she I. B. Addis: Nothing to disclose; K. D. Hatch: Nothing to disclose; J. Heusinkveld: was recovering well with excellent pelvic organ prolapse support. Nothing to disclose. Conclusions: Failure following a sacral colpopexy can be attributed to three possible causes. The mesh can become detached from the sacrum, the cervix/ vagina or undergo a break somewhere in-between. Data regarding the incidence of these complications is limited due to the low failure rate associated with this Video Poster 18 procedure and the reluctance on the part of the surgeon to re-explore the ab- ROBOTIC EXCISION OF SACROCOLPOPEXY MESH AND domen. This video demonstrates the value of performing an abdominal ex- UTEROSACRAL LIGAMENT SUSPENSION: A CASE SERIES ploration in the rare case of prolapse recurrence following a sacral colpopexy. L. Jones, J. Slawin, N. Rosenblum. New York University, New York, NY Additionally, it showcases the uncomplicated procedure of reattaching the sa- Objective: Robotic assisted laparoscopic sacrocolpopexy is a commonly per- cral tail of the Y mesh in the instance where it has separated from the anterior formed procedure to treat prolapse in the apical compartment. While this is an longitudinal ligament. overall safe and durable procedure, potential complications such as chronic Disclosures: A. Holubyeva: Nothing to disclose; K. M. Nicholson: Nothing to pain, infection or erosion of mesh may necessitate mesh excision. Important disclose; P. S. Finamore: Nothing to disclose; D. L. O'Shaughnessy: Tepha: factors to consider in these cases include obscuring of tissue planes due to Grant/Research Support.

also put these patients at risk of complications from more conservative treat- Video Poster 20 ments such as long-term pessary use. Robotic-assisted SC provides an option ROBOTIC SACROCOLPOPEXY WITH VENTRAL RECTOPEXY for these patients that can reduce complications associated with mesh place- R. S. Briskin. Henry Ford Health System, Detroit, MI ment and with laparotomy. Our patient had a favorable outcome at 9 months Objective: The primary objective of this video is to demonstrate a multidisci- post-operatively. plinary surgical approach to evaluation and correction of concomitant rectal Conclusions: Robotic-assisted SC using autologous fascia lata graft can be prolapse and pelvic organ prolapse using a minimally invasive approach with successful and safe in the short-term in patients at increased risk for mesh com- a properly tensioned single synthetic Y-mesh. plication. Additional follow-up is ongoing and prospective studies needed. Methods: A 62-year-old G3P3 woman presented with rectal protrusion with Disclosures: G. H. Melero: Nothing to disclose; J. Nagle: Nothing to disclose; J. constant mucoid discharge, and bothersome vaginal bulge. The rectal protrusion T. Kowalski: Nothing to disclose; C. S. Bradley: Nothing to disclose. had to be reduced manually, but would return with each bowel movement. She reported fecal trapping and need for digitation with bowel movements. She was initially evaluated by her colorectal surgeon, and an incidental enterocele was noted on defecography. She denied urinary symptoms. On exam of all pelvic Video Poster 22 floor compartments, she was found to have a vaginal vault and anterior wall pro- PROPER ASSEMBLYOF A MAGRINA-BOOKWALTER lapse with a leading edge of 0, as well as 3 cm of circumferential rectal prolapse. SELF-RETAINING VAGINAL RETRACTOR Robotic surgical correction was coordinated. A ventral rectopexy was per- Z. S. Cope. University of Louisville, Louisville, KY, S. L. Francis. University of formed initially by dissecting the rectovaginal space to the level of the perineal Louisville, Louisville, KY, O. Cardenas-Trowers. University of Louisville, body, with care to preserve the lateral rectal stalk, and a polypropylene Y-mesh Louisville, KY and A. Gupta. University of Louisville, Louisville, KY was secured at the level of the levator ani. The rectum was tensioned slightly and Objective: There is often a trade-off between surgeon ergonomics and tissue secured to the sacral promontory. The bladder was then dissected off of the an- visualization that can impact vaginal surgery. The use of handheld retractors terior vaginal wall to the level of the bladder neck, and the anterior arm of the by assistants often place them at awkward angles with still suboptimal visualiza- Y-mesh was sutured to the anterior vaginal wall. The mesh was reperitonealized, tion. We present a video demonstrating the components and proper assembly of and a modified Halban’s culdoplasty was performed to prevent enterocele de- the Magrina-Bookwalter Self-Retaining Vaginal Retractor, which not only re- velopment. The postoperative course was without complication, with successful duces the need for surgical assistants to use handheld retractors as frequently resolution of both her rectal prolapse and vaginal vault prolapse. but also provides superior stable global visualization of the surgical field. Clinical Relevance: The incidence of concomitant uterine/vaginal prolapse Methods: The video demonstrates the assembly and use of a Magrina-Bookwalter with rectal prolapse is at least 38%.Approximately 29% of women require more vaginal retractor during a vaginal procedure which illustrates the improved visu- than one operation for pelvic organ prolapse. There is no difference in operative alization for the surgeons and reduced need of the assistants to assume uncom- morbidity when adding sacrocolpopexy to a rectopexy procedure; however, the fortable positioning to achieve adequate visualization overall utilization of combined procedures remains low. A multidisciplinary ap- Results: Video Submission (Please see Clinical Relevance) proach that includes evaluation of all pelvic floor compartments should be im- Conclusions: Video Submission (Please see Clinical Relevance) plemented. Surgical management of the patient with multi-compartment Clinical Relevance: The Magrina-Bookwalter Self-Retaining Vaginal Re- prolapse, can be accomplished with a properly tensioned single Y-mesh. This tractor can help to optimize visualization and minimize awkward positioning approach may limit the number of operative interventions and associated mor- of assistants during vaginal surgery. The components of the Magrina-Bookwalter bidity and costs. are individually labeled and detailed with demonstration of their proper affix- Results: n/a (video) ation to the operating room table and to one another. Care is taken to highlight Conclusions: n/a (video) minute details of assembly that, if performed, can result in increased efficiency Disclosures: R. S. Briskin: Nothing to disclose. of movement.

Video Poster 21 ROBOTIC-ASSISTED LAPAROSCOPIC SACRAL COLPOPEXY (SC) USING AUTOLOGOUS FASCIA LATA GRAFT G. H. Melero1, J. Nagle1, J. T. Kowalski2,C.S.Bradley2. 1University of Kentucky, Lexington, KY, 2University of Iowa Hospitals and Clinics, Iowa City, IA Objective: Sacral colpopexy (SC) with synthetic mesh remains the gold standard treatment of vaginal vault prolapse, providing durable outcomes. However, patient factors (e.g. vaginal atrophy, diabetes, smoking, autoimmune disease) may make mesh use riskier and some patients and surgeons may prefer to avoid mesh. Additionally, patients and surgeons prefer a minimally-invasive approach as this reduces post-operative pain, recovery time and risk of hernia among other complications. To provide durable outcomes via a minimally-invasive approach to select patients, our center has offered robotic-assisted laparoscopic sacral colpopexy with autologous fascia graft, but literature supporting this procedure is lacking. The objectives of this video were to 1) demonstrate the procedure for com- pleting robotic sacral colpopexy with autologous fascia lata graft and 2) report the post-operative outcome in the year following this procedure. Methods: Video was recorded during the procedure with patient permission. FIGURE 1. Patient data and outcome information was collected from retrospective chart re- Magrina-Bookwalter Self-Retaining Vaginal Retractor in view. Video footage was edited and video produced using iMovie software. use during a vaginal hysterectomy; cervix and uterus present. Results: While SC with synthetic mesh remains standard for durable pelvic organ prolapse repair, some patients with prolapse are not good candidates for this procedure. Many conditions can make patients high risk for mesh complications Disclosures: Z. S. Cope: Nothing to disclose; S. L. Francis: Nothing to disclose; including diabetes, smoking, severe vaginal atrophy, immunosuppression, prior O. Cardenas-Trowers: AMAG Pharrmaceuticals: Grant/Research Support; A. pelvic radiation and prior mesh complications. Many of these conditions may Gupta: Nothing to disclose.