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Study Objective: The main objective is to evaluate the feasibility of laparoscopic fertility-sparing surgery in women with growing teratoma syndrome., Design: Retrospective cohort study., Setting: Chinese tertiary university hospital., Patients: Patients with growing teratoma syndrome who underwent fertility-sparing surgery between January 2015 and August 2023., Interventions: Baseline characteristics and surgical outcomes were evaluated, including clinical information, surgical procedures, operative time, intraoperative blood loss, complications, length of hospital stay, and follow-up information., Measurement and Main Results: Twenty-six patients with ovarian growing teratoma syndrome underwent fertility-sparing surgery: 12 had laparoscopic surgery and 14 underwent laparotomic surgery. In the laparoscopic group, the median age of the patients during initial management of immature teratoma or mixed malignant ovarian germ cell tumor was 14.0 years (interquartile range, 13.0-24.5 years). Eleven patients were nulliparous. The primary ovarian tumor was pure immature teratoma in 10 patients and mixed ovarian germ cell tumor in 2 patients. Complete laparoscopic tumor resection was achieved in 11 patients. Patients in the laparoscopic group had shorter median operative time (76.5 vs 180.0 minutes, p = .001), lower estimated blood loss (20.0 vs 400.0 mL, p <.001), and decreased postoperative hospital stay (2.0 vs 7.0 days, p <.001) compared with laparotomic surgery. There was no conversion to laparotomy and no perioperative complications. Histologic examination confirmed mature teratoma in all cases. During a median follow-up of 21.9 months (interquartile range, 7.6-44.9 months), 11 patients were alive without disease and 1 was alive with disease. One pregnancy was achieved postoperatively., Conclusion: Laparoscopic fertility-sparing surgery may represent a feasible option in well-selected patients with ovarian growing teratoma syndrome. Surgery should be performed in gynecologic oncology centers by experienced staff trained in endoscopic procedures. More research and long-time follow-up are needed to determine the oncologic outcomes and safety of laparoscopic surgery in this population., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary., Design: We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures., Results: 224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms., Conclusion: Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal., Competing Interests: Conflict of Interest NL: Advisory Board for Integra LifeSciences Inc.; Speaker honoraria for Pfizer Inc. and Medtronic Inc. MFB: National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH) under Award Number NS123206-01., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To explore the effectiveness of transvaginal natural orifice transluminal endoscopic surgery extraperitoneal sacral hysteropexy (vNOTES-ESH) in women with symptomatic uterine prolapse over a 2 year follow-up., Design: Retrospective cohort study., Setting: Gynecological minimally invasive center., Patients: Women undergoing sacral hysteropexy either by vNOTES (n = 25) or laparoscopic (n = 74) between November 2016 and December 2020., Interventions: Both vNOTES-ESH and laparoscopic sacral hysteropexy (LAP-SH) were used for uterine prolapse. Demographic data, operative characteristics, perioperative outcomes, and follow-up information 2 years postsurgery in the 2 groups were retrospectively evaluated., Results: Both procedures showed similar operation time, estimated blood loss, hospital stays, and pain scores (p >0.05). During a median follow-up of 59 (24-72) months, the surgical success rate was 96% for vNOTES-ESH and 97.3% for LAP-SH (p >0.05), with no differences in anatomical position or pelvic organ function after the operation. Women in the LAP-SH group experienced more bothersome symptoms of constipation compared to those in the vNOTES-ESH group (5.41% vs 0, p <0.05). Lastly, 1 case in the vNOTES-ESH group had a mesh exposed area of less than 1 cm 2 , and 1 patient in the LAP-SH group experienced stress incontinence., Conclusions: In this retrospective study, vNOTES-ESH met our patients' preference for uterine preservation and was a successful and effective treatment for uterine prolapse, providing good functional improvement in our follow-up. This procedure should be considered as an option for patients with pelvic organ prolapse., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To demonstrate identification and dissection of the pelvic autonomic nerves in gynecologic surgery., Design: Identification on the right and left pelvic pelvises, dissection and preservation of the inferior hypogastric plexus in deep endometriosis, and dissection and preservation of the pelvic autonomic nerves in radical hysterectomy., Setting: Academic center., Interventions: Robotic excision of the pelvic peritoneum, excision of deep endometriosis in the uterosacral ligaments, and radical hysterectomy., Conclusion: Pelvic autonomic nerves are easy to identify with the magnification provided with an endoscopic camera. They should be dissected and preserved whenever possible because of their important function., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To provide a perspective on nerve-sparing (NS) surgery in gynecology., Data Sources: Literature review, English language., Methods of Study Selection: Systematic reviews and meta-analyses studies were selected for review for oncology; comparative studies were selected for endometriosis, and 1 comparative and 1 prospective study were chosen for sacrocolpopexy., Tabulation, Integration, and Results: Two tables summarize the results of systematic reviews and meta-analyses in oncology. Oncology, endometriosis, and urogynecology sections. Primary benefit of NS technique is decreased bladder dysfunction, and, to a lesser degree, vaginal and rectal dysfunc., Conclusion: NS is preferable to conventional surgery for benign and malignant conditions to reduce postoperative bladder, rectal, and vaginal dysfunction., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Nearly 10% of the 1.3 million women living with a gynecologic cancer are aged <50 years. For these women, although their cancer treatment can be lifesaving, it's also life-altering because traditional surgical procedures can cause infertility and, in many cases, induce surgical menopause. For appropriately selected patients, fertility-sparing options can reduce the reproductive impact of lifesaving cancer treatments. This review will highlight existing recommendations as well as innovative research for fertility-sparing treatment in the 3 major gynecologic cancers., Tabulation, Integration, and Results: For early-stage cervical cancers, fertility-sparing surgeries include cold knife conization, simple hysterectomy with ovarian preservation, or radical trachelectomy with placement of a permanent cerclage. In locally advanced cervical cancer, ovarian transposition before radiation therapy can help preserve ovarian function. For endometrial cancers, fertility-sparing treatment includes progestin therapy with endometrial sampling every 3 to 6 months. After cancer regression, progestin therapy can be halted to allow attempts to conceive. Hysterectomy with ovarian preservation can also be considered, allowing for fertility using assisted reproductive technology and a gestational carrier. For ovarian cancers, fertility-sparing surgery includes unilateral salpingo-oophorectomy or bilateral salpingo-oophorectomy (with lymphadenectomy and staging depending on tumor histology). With higher-risk histology or higher early-stage disease, adjuvant chemotherapy is recommended-however, this carries a 3% to 10% risk of ovarian failure. Use of oocyte or embryo cryopreservation in patients with early-stage ovarian malignancy remains an area of ongoing research., Conclusion: Overall, fertility-sparing management of gynecologic cancers is associated with acceptable rates of progression-free survival and overall survival and is less life-altering than more radical surgical approaches., (Copyright © 2021 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To show technical highlights of a nerve-sparing laparoscopic eradication of deep endometriosis (DE) with posterior compartment peritonectomy., Design: Demonstration of the technique with narrated video footage., Setting: An urban general hospital. A systematic review and meta-analysis has suggested significant advantages of the nerve-sparing technique when considering the relative risk of persistent urinary retention in the treatment of DE [1]. In addition, a recent article has suggested that complete excision of DE with posterior compartment peritonectomy could be the surgical treatment of choice to decrease postoperative pain, improve fertility rate, and prevent future recurrence [2]. However, in DE, nerve-sparing procedures are even more challenging than oncologic radical procedures because the pathology resembles both ovarian/rectal cancer in terms of visceral involvement and advanced cervical cancer in terms of wide parametrial infiltration through the pelvic wall., Interventions: The video highlights the anatomic and technical aspects of a fertility- and nerve-sparing surgery in DE with posterior compartment peritonectomy. After adhesiolysis and ovarian surgery, we developed retroperitoneal space at the level of promontory. The hypogastric nerve consists of the upper edge of the pelvic plexus, therefore the autonomic nerves were separated in a "nerve plane" by sharp interfascial dissection of the loose connective tissue layers both above (between the fascia propria of the rectum and the prehypogastric nerve fascia) and below (between the prehypogastric nerve fascia and the presacral fascia) the hypogastric nerve [3,4]. As a result of these dissections, the autonomic nerves in the pelvis were separated like a sheet with surrounding fascia. We then completely resected all DE lesions including peritoneal endometriosis while avoiding injury to the nerve plane. In a small number of our experiences, none of the patients (n = 51) required clean intermittent self-catheterization after this procedure., Conclusion: Fertility- and nerve-sparing laparoscopic eradication of DE with total posterior compartment peritonectomy is a feasible technique and may provide both curability of DE and functional preservation. Our nerve-sparing technique can reproducibly simplify this complex procedure., (Copyright © 2020. Published by Elsevier Inc.)

Study Objective: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes., Design: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ 2 test and the Fisher exact test. A p-value <.05 was considered significant., Setting: Teaching hospital., Patients: Forty patients who underwent TULH from 2009 to 2017., Interventions: TULH., Measurements and Main Results: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP., Conclusion: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients., Design: A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus., Setting: The surgeries were performed in a single institution between January 2015 and June 2019., Patients: The patients were selected if a laparoscopic intervention was indicated., Interventions: The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture., Measurements and Main Results: Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up., Conclusion: LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To show the safety and feasibility of laparoscopic sacrohysteropexy for treating uterine prolapse., Design: An educational video to explain the laparoscopic steps of this procedure by focusing on the main anatomic landmarks and on tips and tricks to avoid complications., Setting: A tertiary care university hospital., Interventions: Laparoscopic sacropexy with uterus preservation for grade 3 apical defect., Conclusion: This video shows a stepwise approach to laparoscopic sacrohysteropexy demonstrating its feasibility and safety. There is a wide choice of surgical procedures and approaches focused on pelvic organ prolapse repair. Since many years, uterine prolapse has been an indication for hysterectomy, regardless of the occurrence of uterine disease and patients' desires. With the introduction of minimally invasive surgery, the uterine-sparing procedures are being increasingly taken into account, especially in young women [1]. Sacrohysteropexy is a uterus-sparing procedure that allows for a reduction in operating time, intraoperative blood loss, mesh-related complications, and surgical costs [2]. Furthermore, this technique has a high success rate with an objective cure rate of 100% for the apical compartment and 80% for all compartments and does not seem to increase the pelvic organ prolapse recurrence rate [3]. Sacropexy is not a life-threatening procedure, but its main objective is to restore functional anatomy with the primary goal of improvement in patient's quality of life. Moreove, no difference has been found with or without uterus preservation in term of postoperative recurrence rate or ent's quality of life [4]. However, high patient satisfaction has been recently reported; therefore, uterine preservation should be considered during patient's counseling., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To explore the feasibility of nerve plane-sparing laparoscopic radical hysterectomy (NPS-LRH) as a simplified C1-type surgery for cervical cancer patients and to compare this technique with laparoscopic radical hysterectomy (LRH)., Design: A retrospective comparative study., Setting: An academic tertiary hospital affiliated with the Chinese National Cancer Center., Patients: Six hundred fifteen patients with Fédération Internationale de Gynécologie et d'Obstétrique stage Ib and IIa cervical cancer who underwent laparoscopic radical hysterectomy between January 2010 and December 2017 were enrolled. Among them, 263 patients underwent the NPS-LRH surgery, and 352 patients underwent the LRH surgery. Intraoperative data and postoperative outcomes were compared between the 2 groups., Interventions: NPS-LRH is a simplified type C1 procedure that preserves the ureteral mesentery and its nerve plane, whereas LRH is a type C2 procedure in the Querleu-Morrow surgical classification system., Measurements and Main Results: There were no statistically significant differences in age, body mass index, Fédération Internationale de Gynécologie et d'Obstétrique stage, tumor differentiation, pathological type, depth of invasion, lymphovascular space invasion, parametrial tissue invasion, lymphatic metastasis, neoadjuvant chemotherapy, or postoperative adjuvant radiotherapy and chemotherapy between the 2 groups. Compared with the LRH group, the NPS-LRH group had a shorter length of operation (238.7 ± 53.9 minutes vs 259.8 ± 56.6 minutes, p < .01), less intraoperative bleeding (p < .01), more resected lymph nodes (p = .028), shorter duration of urinary catheterization (p < .01), lower incidences of postoperative hydronephrosis (p = .044), less long-term frequent urination (p < .01), less acute urinary incontinence (p < .01), poor bladder sensation (p = .028), and constipation (p = .029). There were no statistically significant differences in the disease-free survival and overall survival between the 2 groups (p = .769 and .973, respectively)., Conclusion: NPS-LRH is a simplified, safe, and feasible type C1 operation that had a shorter length of operation, less intraoperative bleeding, more resected lymph nodes, and better postoperative bladder function compared with the LRH group. Further studies are required to assess its benefits on rectal function and long-term prognosis., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To show technical highlights of a nerve-sparing laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the Negrar method., Design: Stepwise demonstration of the technique with narrated video footage., Setting: Tertiary care endometriosis unit. Bowel endometriosis accounts for about 12% of the total cases of endometriosis. Most frequently, rectal infiltration also means parametrial infiltration from the widespread infiltrating disease. Its removal with inadequate anatomical surgical knowledge may lead to severe damage to visceral pelvic innervation, causing bladder, rectal, and sexual function impairments and lasting lifelong. Nerve-sparing techniques, which are the heritage of onco-gynecologic surgery, have been described to have lower post-operative bladder, rectal, and sexual dysfunctions than classical approaches., Interventions: Laparoscopic excision of deep infiltrating endometriosis was performed by following the nerve-sparing Negrar technique in 6 steps: step 0-adhesiolysis, ovarian surgery, and removal of the involved peritoneal tissues; step 1-opening of pre-sacral space, development of avascular spaces, and identification and preservation of pelvic sympathetic fibers of the inferior mesenteric plexus, superior hypogastric plexus, upper hypogastric nerves, and lumbosacral sympathetic trunk and ganglia; step 2-dissection of parametrial planes, isolation of ureteral course, lateral parametrectomy, and preservation of sympathetic fibers of postero-lateral parametrium and lower mesorectum (the lower hypogastric nerves and proximal part of the inferior hypogastric plexus or pelvic plexus); step 3-posterior parametrectomy, deep uterine vein identification, and preservation of the parasympathetic pelvic splanchnic nerves and the cranial and middle part of the mixed inferior hypogastric plexus in caudad posterior parametrium and lower mesorectal planes; step 4-preserving the caudad part of the inferior hypogastric plexus in postero-lateral parametrial ligaments; step 5-preserving the caudad part of the inferior hypogastric plexus in paravaginal planes; and step 6-rectal resection and colorectal anastomosis., Conclusion: As shown in this case, the laparoscopic nerve-sparing complete excision of endometriosis is a feasible and reproducible technique in expert hands and, as reported in the literature, offers good results in terms of bladder morbidity reduction with higher satisfaction than the classical technique., (Copyright © 2019. Published by Elsevier Inc.)

Objective: The purpose of this systematic review was to identify the operative issues and specific dysmenorrhea and menorrhagia outcomes in women who had undergone fertility-sparing surgery, as well as determine the expected outcome for extirpative surgery., Data Sources: PROSPERO (ID no. 125692). Search was conducted for eligible studies up to March 31, 2019, on MEDLINE/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). The search terms applied for the search strategy were as follows: adenomyosis, adenomyomas, uterus-sparing surgery, fertility-sparing surgery, pain, dysmenorrhea, menorrhagia, uterine volume, adenomyotic volume, case-control studies, cohort studies, and prospective studies., Methods of Study Selection: A total of 443 studies were initially identified. Exclusion criteria was as follows: (1) inadequate description of preoperative adenomyosis or absence of postoperative histology confirmation of adenomyosis, (2) no statement of use of a standardized instrument for measurement of pain, bleeding, or adenomyotic/uterine volume, (3) follow-up <12 months postoperatively, (4) study population <20 women, and (5) non-English language., Tabulation, Integration, and Results: Nineteen studies with a total of 1843 patients with adenomyosis were included. Twelve studies were further analyzed in the meta-analysis. Complete excision of adenomyosis was associated with improvement in pain, menorrhagia, and reduction of uterine volume by a factor of 6.2, 3.9, and 2.3, respectively; the partial excision of adenomyosis was associated with improvement in pain, menorrhagia, and reduction of uterine volume by a factor of 5.9, 3.0, and 2.9, respectively; the studies with a mixed volume of patients with complete and partial excision of adenomyosis reported improvement in pain, menorrhagia, and reduction of uterine volume by a factor of 4.0, 6.3, and 5.1, respectively., Conclusion: The surgical treatment of adenomyosis results in the satisfactory control of pain and bleeding, as well as in the reduction of uterine volume. Further research is warranted to investigate the long-term control of symptoms to identify any parameters related to the recurrence of adenomyosis, as well as to compare the conservative surgical treatment of adenomyosis with other treatment options., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To clarify the relationship of hypogastric nerves (HNs) with several pelvic anatomic landmarks and to assess any anatomic differences between the 2 sides of the pelvis, both in cadaveric and in vivo dissections., Design: Prospective observational study., Setting: An anatomic theater for cadaveric dissections and a university hospital for in vivo laparoscopy., Patients: Five nulliparous female cadavers underwent laparotomic dissection; 10 nulliparous patients underwent laparoscopic surgery for rectosigmoid endometriosis without posterolateral parametrial infiltration., Interventions: Measurements of the closest distance between HNs and ureters, the midsagittal plane, the midcervical plane, and uterosacral ligaments on both hemipelvises. A comparison of anatomic data of the 2 hemipelvises was conducted., Measurements and Main Results: The right and left HNs were identified in all specimens, both on cadavers and in vivo dissections. A wide anatomic variability was reported. Regarding the differences between the 2 hemipelvises, we found that the right HN was significantly (p <.001) farther to the ureter (mean = 14.5 mm; range, 10-25 mm) than the left one (mean = 8.6 mm; range, 7-12 mm). The HN was closer to the midsagittal plane on the right side (mean = 14.6 mm; range, 12-17 mm) than on the left side (mean = 21.6 mm; range, 19-25 mm). The midcervical plane was found 2.7 mm (range, 2-4 mm) to the left of the midsagittal one. The right HN was found to be nonsignificantly closer to the midcervical plane and the uterosacral ligament on the right side than on the left side (p >.05)., Conclusions: Despite a wide anatomic variability of position and appearance, the HNs are reproducibly identifiable using an "interfascial" technique and considering the ureters and uterosacral ligaments as anatomic landmarks., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To examine the surgical management and outcomes of patients treated laparoscopically for pelvic pain following ovary-sparing hysterectomy., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: General gynecology unit at a tertiary university hospital., Patients: A total of 99 patients treated with laparoscopic oophorectomy for pelvic pain following ovary-sparing hysterectomy between January 2008 and December 2016., Interventions: Laparoscopic oophorectomy was performed in all patients., Measurements and Main Results: The patients undergoing surgery had a mean age of 48.9 years and a mean body mass index (BMI) of 28.1. They reported a mean of 3.0 previous abdominal surgeries. Sixty percent of patients reported previous abdominal hysterectomy, 21% had previous laparoscopic hysterectomy, and 19% had previous vaginal hysterectomy. At a 6-week follow-up, 59.5% of patients reported resolution of symptoms, 10.7% reported persistent symptoms, and 29.8% reported improved but not resolved symptoms. Younger patients and those reporting a previous history of gastrointestinal disease were more likely to report persistent pain at follow-up. Thirteen percent of patients had intraoperative (6%) or postoperative complications (7%), and there was a 2% rate of conversion to laparotomy. Patients at greater risk of intraoperative complications were those with a higher BMI, a greater number of previous open abdominal surgeries, or severe adhesions noted at the time of procedure., Conclusions: Laparoscopic oophorectomy to treat pelvic pain following ovary-sparing hysterectomy is a feasible yet challenging procedure. Despite a significant rate of complications and a small proportion of patients reporting persistent symptoms, most experience symptom resolution or improvement after such surgery. Further studies are needed to assess long-term outcomes. Careful patient selection and counseling are critical before this procedure., (Copyright © 2018. Published by Elsevier Inc.)

Study Objective: To show a case of laparoscopic excision of an ovarian ectopic pregnancy and the technique used., Setting: A university hospital (Manchester University Foundation Trust)., Patient: A 23-year-old primigravida presentation at 6 weeks of gestation with an ectopic pregnancy., Intervention: A 23-year-old primigravida presentation at 6 weeks of gestation with a 7-day history of light bleeding and intermittent abdominal pain. The examination was unremarkable, and the serum human chorionic gonadotropin level was 7157 IU/L. An ultrasound scan showed an ectopic pregnancy in the right adnexa, and she underwent surgical management. At laparoscopy, both fallopian tubes were noted to be normal with an ectopic pregnancy within the right ovary; 20 IU argipressin diluted in 80 mL 0.9% sodium hypochlorite was injected between the normal ovarian tissue and the ectopic pregnancy to assist hemostasis and hydrodissection. An ultrasonic device was used to incise the ovarian cortex to identify a plane of dissection between the ectopic pregnancy tissue and the normal ovarian tissue. The ectopic pregnancy was excised with conservation of the ovary. The ovary was subsequently closed with absorbable sutures to ensure hemostasis. The ectopic pregnancy was removed in a bag through a 10-mm incision., Measurements and Main Results: The patient made an uneventful recovery. The serum human chorionic gonadotropin level in 7 days was <5, and no further medical management was indicated. Histology confirmed a primary ovarian ectopic pregnancy. Ovarian function was not assessed postoperatively; however, she conceived 6 weeks later with an intrauterine pregnancy., Conclusion: This case highlights the importance of considering nontubal ectopic pregnancies when making a diagnosis based on an ultrasound scan. Ovarian preservation with excision of ectopic pregnancy can be achieved using techniques commonly used for ovarian cystectomy. Recourse to oophorectomy should only be considered in the event of acute hemorrhage., (Copyright © 2019. Published by Elsevier Inc.)

It is widely accepted that nerve-sparing radical hysterectomy is associated with less postoperative morbidity compared with radical hysterectomy, whereas clinical safety is similar in the 2 procedures. However, there is insufficient evidence to compare these procedures performed via a laparoscopic approach. We performed a systematic review and meta-analysis of studies to compare the clinical efficacy and the rate of bladder dysfunction, including urodynamic assessment, in laparoscopic nerve-sparing radical hysterectomy (LNSRH) and laparoscopic radical hysterectomy (LRH). Thirty articles including a total of 2743 participants were analyzed. Operating times were shorter (MD, 29.88 minutes; 95% confidence interval [CI], 11.92-47.83 minutes) and hospital stays were longer (MD, -1.56 days; 95% CI, -2.27 to -0.84 days) in the LRH group compared with the LNSRH group. In addition, blood loss and the number of resected lymph nodes were not significantly different between the 2 groups. However, resected parametrium length (MD, -0.02 cm; 95% CI, -0.05 to -0.00 cm) and vaginal cuff width (MD, -0.06 cm; 95% CI, -0.09 to -0.04) were smaller in the LNSRH group. Furthermore, LNSRH tended to result in more satisfactory micturition (odds ratio, 2.90; 95% CI, 2.01-4.19), shorter catheterization time (MD, -7.20 days; 95% CI, -8.10 to -6.29 days), and shorter recovery to normal postvoid residual urine time (MD, -7.71 days; 95% CI, -8.92 to -6.50 days). Other bladder dysfunction symptoms, including urinary retention, nocturia, dysuria, urinary incontinence, and frequency/urgency were more frequent in the LRH group. Furthermore, LNSRH achieved better results in urodynamic assessments (all p < .05). In conclusion, LNSRH was associated with lower rates of impaired bladder function and a shorter extent of resection compared with LRH. Clinical applications involving LNSRH should be explored with caution., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate a mesh-free laparoscopic uterosacral suture sacrohysteropexy (LUSSH)., Design: Technical video demonstrating LUSSH for uterine prolapse (Canadian Task Force classification III)., Setting: University hospital., Patient: A 37-year-old woman with grade 3 uterine descent requested uterine-sparing surgery for symptomatic prolapse. The patient declined all mesh procedures., Intervention: Mesh-free laparoscopic uterosacral suture sacrohysteropexy (LUSSH)., Measurements and Main Results: Laparoscopic sacrohysteropexy is a uterine-preserving technique for uterine prolapse with high cure rates (92%) but with a mesh erosion risk of up to 2.5% [1,2]. Complications have resulted in reclassification of transvaginal meshes as restricted-use high-risk medical devices [3,4]. Sacrospinous hysteropexy and uterosacral ligament suspension are mesh-free alternatives, but they have increased rates of anterior-compartment failures and a 20% recurrence rate in the latter [5,6]. Laparoscopic suture sacrohysteropexy has been described with reported success rates of 95% [7]. This video demonstrates a modified-technique offering a simple, robust, and reproducible mesh-free approach to uterine-preserving prolapse surgery. We used 2 horizontal loop mattress sutures acting as a pulley to distribute the force evenly throughout the suture strand, leading to a significantly stronger and more secure hold and reducing risk of avulsion [8]. The technique starts with a careful dissection of the peritoneum from the sacral promontory to the cervix. Two permanent sutures are used, taking bites at the anterior longitudinal ligament, the uterosacral, a loop mattress in the midline at the cervix, the uterosacral on the way back, and finally at the sacral promontory. Damage to the uterine vessels is minimized by maintaining a central uterine position. The stitch is tied with caudal pressure on the uterus, applied via the uterine manipulator, approximating the cervix to the sacral promontory. The peritoneum is closed with dissolvable sutures, burying the Ethibond to prevent exposure and bowel obstruction., Conclusion: Post-procedure, the uterus was well supported with a vaginal length of 15 cm., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Study Objective: Radical trachelectomy has emerged as a valuable fertility-preserving treatment option for young women with early-stage cervical cancer [1]. Laparoscopic radical trachelectomy performed by trained surgeons can be a feasible and safe therapeutic option as a fertility-sparing surgical technique [2,3]. To the best of our knowledge, this is the first time the total laparoscopic approach of radical trachelectomy is being published. In this video, rather than the description of the technique step by step, we show how to conserve uterine arteries even if the importance of such conservation is questionable., Design: A case report., Setting: A tertiary referral center in Strasbourg, France., Patient: A 37-year-old patient with no medical history who presented with stage IB1 invasive epidermoid cervical cancer., Intervention: In this video, we describe the fertility-sparing surgical procedure consisting of type B total laparoscopic radical trachelectomy with uterine artery preservation. The procedure consists of the following 10 steps: step 1, bilateral pelvic lymphadenectomy and opening of the para vesical fossa; step 2, opening of the pararectal fossa in between the ureter and the internal iliac artery on each side; step 3, ureteric dissection up to the ureteric canal; step 4, opening of the vesicouterine space and section of the vesicouterine ligament; step 5, posterior dissection with division of the uterosacral ligament approximately 20 mm from the uterine insertion; step 6, section of the descending branch of the uterine artery and skeletonization of the ascending branch up to the uterine isthmus level; step 7, trachelectomy with a monopolar hook; step 8, laparoscopic isthmovaginal stitches; step 9, laparoscopic cerclage; and step 10, peritoneal closure., Measurements and Main Results: The operative time was 420 minutes. The intraoperative blood loss was <200 mL. The operation was performed successfully with no intraoperative complications. The resection margins were safe. The patient was discharged on day 4. After 2 months, no late complications or recurrence were detected, and the patient had normal menstruation., Conclusion: Type B laparoscopic radical trachelectomy with uterine artery preservation appears to be a safe option for women who intend to maintain their desire for a future pregnancy., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To show the feasibility and safety of nerve-preserving laparoscopic radical hysterectomy (type C1 Querleu-Morrow Classification [1]) for the treatment of early cervical cancer., Design: A surgical video article (Canadian Task Force classification III)., Setting: A university hospital (University Hospital of Barcelona, Barcelona, Spain)., Patients: Nerve-preserving radical hysterectomy is performed in a patient with Fédération Internationale de Gynécologie et d'Obstétrique stage 1B1 cervical cancer with deep stromal invasion., Interventions: Three steps are fundamental for the removal of the cérvix with a safe oncologic margin and preservation of the pelvic autonomic nerves [2]. 1. Step 1: for the correct preservation of the pelvic splanchnic nerves (ventral roots from spinal nerves S2-S4) and the inferior hypogastric plexus during the section of the paracervix, it is essential to identify the deep uterine vein. This vein will correspond with the inferior limit of the dissection. 2. Step 2: during the dissection of the uterosacral ligament and after dissecting the Okabayashi space, the inferior hypogastric nerve is isolated. This nerve runs 2 cm parallel below the uterosacral ligament in the peritoneal leaf of the broad ligament. 3. Step 3: during the section of the vesicouterine ligament, the lateral side must be preserved because it includes the medial and inferior vesical veins that drain to the deep uterine vein., Conclusion: Nerve-sparing laparoscopic radical hysterectomy is an attractive surgical approach for early-stage cervical cancer. Direct visualization of the pelvic autonomic nervous system (sympathetic and parasympathetic branches) innervating the bladder and rectum makes the nerve-sparing approach a safe and feasible procedure., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Few studies have investigated the efficacy and safety of the nerve-sparing approach via minimally invasive surgery for the treatment of cervical cancer. We aimed to review the current evidence comparing nerve-sparing minimally invasive radical hysterectomy (NS-MRH) with conventional minimally invasive radical hysterectomy (MRH). This systematic review was registered in the International Prospective Register of Systematic Reviews (CRD#57655). Overall, 675 patients were included: 350 (51.9%) and 325 (48.1%) patients undergoing MRH and NS-MRH, respectively. MRH was associated with a shorter operative time in comparison with NS-MRH (mean difference = 32.57 minutes; 95% CI, 22.87-42.48). The estimated blood loss (mean difference = 97.14 mL, 20.01-214.29) and transfusion rate (odds ratio [OR] = 0.67; 95% confidence interval [CI], 0.15-3.01) did not differ statistically between the 2 groups. The risk of developing intraoperative (OR = 0.43; 95% CI, 0.08-2.23) and severe postoperative (OR = 0.63; 95% CI, 0.17-2.39) complications was similar between NS-MRH and MRH. Patients undergoing NS-MRH experienced lower voiding (OR = 0.39; 95% CI, 0.19-0.81) dysfunction rates than patients undergoing MRH. Moreover, a trend toward lower sexual (OR = 0.25; 95% CI, 0.06-1.07) and rectal (OR = 0.12; 95% CI, 0.01-1.02) issues was observed for patients having NS-MRH compared with patients undergoing MRH. Survival outcomes are not influenced by the type of surgical approach (recurrence [OR = 1.27; 95% CI, 0.49-3.28] and death [OR = 1.01; 95% CI, 0.36-2.83]) rates. The pooled data suggested that NS-MRH is equivalent to MRH for the treatment of cervical cancer and may be superior in reducing pelvic floor dysfunction rates. However, because of the low level of evidence of the included studies, further randomized trials are warranted., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate the added value of the fluorescence dye indocyanine green (ICG) for sentinel lymph node (SLN) mapping in women with cervical cancer who had undergone previous conization (stage 1A-1B1) by comparing ICG versus Tc99 m radiotracer + blue dye (BD)., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: Two European academic medical centers, San Gerardo Hospital, Italy and University of Berne, Switzerland., Patients: Sixty-five women with early stage (IA-IB1) cervical cancer who had undergone previous conization and who underwent SLN mapping with Tc99 m  ± BD (n = 23) or ICG (n = 42) followed by pelvic lymphadenectomy and fertility-sparing surgery or hysterectomy were included in this analysis., Intervention: Overall detection rate and bilateral SLN mapping rates of ICG were compared with those obtained using the standard Tc99 m radiocolloid and BD., Measurement and Main Results: Overall, 220 SLNs were detected. The median number of SLNs per patient in the Tc99 m  ± BD group was 2 (range, 1-5) and in the ICG group, 3 (range, 2-15). The detection rate of SLNs was 95.7% in Tc99 m  ± BD group and 100% in the ICG group (p = .354). The women injected with ICG had a higher rate of bilateral mapping of the SLNs as compared with the Tc99 m  ± BD group (95.2% vs 69.6%, p = .016%). Only 12% of the patients (8/65) presented metastatic nodes, 2 in the Tc99 m  ± BD group and 6 in the ICG group., Conclusion: In early-stage cervical cancer patients conization had no significant impact on the SLN detection rate using both techniques (ICG and radiotracer ± BD). In this scenario a higher bilateral mapping rate was confirmed using the fluorescent dye ICG rather than the standard techniques., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Patients affected by the presence of leiomyomas may incur a substantial physical, emotional, social, and financial toll as well as losses in their quality of life. Although many myomas are not amenable to medical therapy or hysteroscopic resection, many others are amenable to minimally invasive surgical approaches. In patients who prefer to retain their fertility, laparoscopic myomectomy should be considered the intervention of choice. In this review, we expand on the surgical techniques of both conventional laparoscopic and robotic-assisted myomectomies. We discuss port placement, enucleation of myomas, tissue extraction, minimization of blood loss, adhesion prevention, and the technique for closure of uterine incisions. Finally, we discuss the available data supporting the use of these 2 approaches as the preferred, safe, and effective fertility-sparing surgical option. We also briefly discuss the emerging technologies of uterine artery embolization, ultrasound surgery, and radiofrequency ablation., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To delineate the use of opportunistic salpingectomy over the study period, to examine factors associated with its use, and to evaluate whether salpingectomy was associated with perioperative complications., Design: A retrospective cross-sectional study (Canadian Task Force classification II-2)., Setting: The Michigan Surgical Quality Collaborative., Patients: Women undergoing ovarian-conserving hysterectomy for benign indications from January 2013 through April 2015., Interventions: The primary outcome was the performance of opportunistic salpingectomy with ovarian preservation during benign hysterectomy. The change in the rate of salpingectomy was examined at 4-month intervals to assess a period effect over the study period. Multivariate logistic regression was performed to evaluate independent effects of patient, operative, and period factors. Perioperative outcomes were compared using propensity score matching., Measurements and Main Results: There were 10 676 (55.9%) ovarian-conserving hysterectomies among 19 090 benign hysterectomies in the Michigan Surgical Quality Collaborative in the study period. The rate of opportunistic salpingectomy was 45.8% (n = 4890). Rates of opportunistic salpingectomy increased over the study period from 27.5% to 61.6% (p < .001), demonstrating a strong period effect in the consecutive 4-month period analysis. Salpingectomy was more likely with the laparoscopic approach (odds ratio = 3.48; 95% confidence interval, 3.15-3.85) and among women younger than 60 years of age (odds ratio = 1.60; 95% CI, 1.34-1.92). There was substantial variation in salpingectomy across hospital sites, ranging from 3.6% to 79.9%. Salpingectomy was associated with a 12-minute increase in operative time (p < .001), but there were no differences in the estimated blood loss or perioperative complications., Conclusion: The rates of salpingectomy increased significantly over the study period. The laparoscopic approach and younger age are associated with an increased probability of salpingectomy. Salpingectomy is not associated with increased blood loss or perioperative complications., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate surgical techniques utilized during uterine-sparing laparoscopic resections of accessory cavitated uterine masses (ACUMs). ACUMs represent a rare uterine entity observed in premenopausal women suffering from dysmenorrhea and recurrent pelvic pain. The diagnosis is made when an isolated extra-cavitated uterine mass is resected from an otherwise normal appearing uterus with unremarkable endometrial lumen and adnexal structures. Pathologic confirmation requires an accessory cavity lined with endometrial epithelium (and corresponding glands and stroma) filled with chocolate-brown fluid. Adenomyosis must be absent. Although the origin of ACUMs is currently unknown, the most common presentation is a 2-4 cm lateral uterine wall mass at the level of the insertion of the round ligament. Hence it has been hypothesized that gubernaculum dysfunction may be responsible for duplication or persistence of paramesonephric tissue leading to ACUM formation as a new Müllerian anomaly., Design: A stepwise surgical tutorial describing 2 laparoscopic ACUM resections using a narrated video (Canadian Task Force classification III)., Setting: An academic tertiary care hospital., Patients: In this video, we present 2 patients who underwent uterine-sparing laparoscopic resections of their ACUM in order to preserve fertility (Case 1) or avoid the complications and surgical recovery time of a total laparoscopic hysterectomy (Case 2). Case 1 is a 19-year-old, gravida 0, para 0 woman with dysmenorrhea and recurrent pelvic pain who presented for multiple emergency room and outpatient evaluations. Transvaginal ultrasonography was unremarkable except for a 28×30×26mm left lateral uterine mass with peripheral vascular flow that was initially felt to be a leiomyoma or rudimentary uterine horn. MRI imaging, however, demonstrated this mass to be more consistent with an ACUM. This was based on the lack of communication between the lesion and the main uterine cavity exhibited by high T2 signal (compatible with endometrial tissue) surrounding low T2/high T1 signal in the dependent aspects (representing blood products). After counseling regarding treatment options including medical management with hormonal contraception, the patient elected for definitive fertility preserving laparoscopic resection. In contrast, case 2 is a 39-year-old, gravida 3, para 3 woman with a 2 month history or left lower quadrant pain following her last vaginal delivery. Transvaginal ultrasonography showed a 23×18×19mm cystic structure within the left uterine wall, which was confirmed to represent an ACUM on MRI. Although she had no desire for fertility preservation, the patient elected for surgical resection of the mass as opposed to a hysterectomy in order to minimize complications and recovery time., Interventions: Laparoscopic resection of ACUMs in patients desiring uterine preservation., Measurements and Main Results: Laparoscopic resection of the ACUMs was performed utilizing 2 different techniques. In both cases, dilute vasopressin was injected with a modified butterfly or spinal needle along the uterine-ACUM serosal interphase to aid with hemostasis. In patients desiring to preserve fertility (case 1) monopolar energy is utilized to make an incision along the ACUM serosa to help facilitate dissection. ACUM enucleation is then commenced in a circumferential manner along the ACUM and uterine myometrial interphase utilizing bipolar energy. In contrast to leiomyomas where dissection advances along the pseudocapsule, ACUM have poorly delineated borders with disorganized muscular fibers making dissection particularly difficult. A variety of instruments can be utilized to help in the sequential circumferential dissection in addition to a bipolar device including a single-tooth tenaculum, myoma hook, suction device or fine-needle grasper. Ultimately, the ACUM is transected off its uterine-myometrial attachment and hemostasis is obtain before closing the uterine defect in at least 2 layers using a 2-0 barbed V-Loc (Medtronic, Minneapolis, MN). If fertility preservation is no longer desired, the dissection can greatly be expedited by performing a salpingectomy and skeletonizing the ACUM from the leaves of the broad ligament (case 2). A monopolar L-hook can then be used to transect the ACUM from the remaining uterine body. While difficult, these cases can be completed laparoscopically in approximately 2 hours with minimal blood loss., Conclusions: ACUMs are hypothesized to represent a previously under recognized Müllerian anomaly linked to gubernaculum dysfunction that occurs in premenopausal women with dysmenorrhea and chronic pelvic pain. Uterine and fertility sparing laparoscopic resection is possible but challenging due to poorly defined planes., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate hysteroscopic transcervical resection (TCR) for atypical polypoid adenomyoma of the uterus (APA)., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: Single tertiary hospital., Patients: Women who underwent TCR for APA at Kawasaki Municipal Hospital between 2003 and 2015., Interventions: Clinical records were obtained., Measurements and Main Results: Thirty-five patients with APA were evaluated. The median patient age was 35 years (range, 23-43 years), and the median tumor diameter was 22 mm (range, 9-51 mm). The median duration of observation after the first TCR was 34.0 months (range, 4.2-133.7 months). In 19 patients, the tumor recurred after the first TCR. A second TCR was performed in 13 patients, 11 of whom experienced recurrence. A third TCR was performed in 7 patients, all 7 of whom experienced recurrence. A fourth TCR was performed in 4 patients, 3 of whom experienced recurrence. The recurrence rate after the second TCR was higher than that after the first TCR (71.4%-84.6% vs 54.3%; p < .01, t test). The median disease-free interval was 12.4 months after the first TCR, 15.3 months after the second TCR, 10.5 months after the third TCR, and 10.9 months after the fourth TCR. Seven patients progressed to endometrial cancer; however, there was no mortality. Six of the 35 patients conceived, and 4 had a normal spontaneous delivery., Conclusion: Owing to disease-free intervals that follow treatment, TCR is a promising treatment modality as a fertility-preserving option for patients with APA under careful observation. Twenty percent of patients with APA develop cancer; however, the present study showed no mortality., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate vaginal salpingectomy techniques in the presence of ovarian conservation., Design: Technical video demonstrating 2 methods of Fallopian tube removal with illustrations (Canadian Task Force classification III)., Setting: The prevalence of salpingectomy at the time of hysterectomy has increased significantly since 1998 [1]. One reason for the increased rate of salpingectomy is the relationship of serous ovarian carcinomas to fimbrial serous tubal intraepithelial carcinomas [2]. A Swedish population-based study reported that salpingectomy is an effective measure to reduce ovarian cancer risk in the general population [3]. Prophylactic salpingectomy and delayed oophorectomy may be an acceptable alternative in some BRCA mutation carriers [4]. A retrospective cohort study of 425 vaginal hysterectomies showed that 88% of patients were able to successfully undergo concomitant salpingectomy [5]. Mayo Clinic Institutional Review Board approval was not required for this video article., Intervention: Two methods of salpingectomy are demonstrated differing in the final disposition of the proximal Fallopian tube (segment). The 2 different methods are shown to increase clarity and understanding of the technique., Conclusion: Salpingectomy without concomitant removal of the ovaries at vaginal hysterectomy is a feasible and beneficial procedure., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate safety, feasibility, and long-term clinical effects of adding laparoscopic pelvic plexus ablation to uterine-sparing procedures (uterine artery occlusion and partial adenomyomectomy) for adenomyosis., Design: A prospective controlled study (Canadian Task Force classification II-1)., Setting: A teaching hospital., Patients: A total of 112 patients with symptomatic adenomyosis were eligible for uterine-sparing laparoscopy., Interventions: Laparoscopic pelvic plexus ablation, uterine artery occlusion, and partial adenomyomectomy., Measurements and Main Results: After the exclusion of patients with malignant tumors or those lost to follow-up, 102 women underwent laparoscopic uterine artery occlusion and partial adenomyomectomy; 50 of these patients also had laparoscopic uterine pelvic plexus ablation (group A) with the remaining 52 patients serving as the control group (group B). Other than operative time (107.0 ± 15.4 vs 98.9 ± 20.2 minutes, p = .02), there were no statistical differences regarding other operative parameters between groups A and B. Relief of severe dysmenorrhea (Visual Analogue Scale score ≥ 7) at 36 months was higher in group A than in group B (100% vs 76.9%, p < .01). No patient suffered constipation or uroschesis in either group., Conclusion: Adding laparoscopic uterine pelvic plexus ablation to laparoscopic uterine artery occlusion and partial adenomyomectomy was more effective in relieving dysmenorrhea., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To compare the clinical and oncological outcomes of four different approaches of cervical excision (CE) during radical trachelectomy (RT) for early cervical cancer., Design: A retrospective comparative observational study was performed at Gynecology Department of the Hospital Italiano de Buenos Aires in Buenos Aires, Argentine. The study was composed of all consecutive women who had undergone laparoscopic RT for early cervical cancer between May 2011 and July 2016. They were divided in four groups according with different surgical approaches to perform the CE during RT; which are also detailed. (Canadian Task Force Classification III)., Setting: Tertiary care hospital., Intervention: CE during radical trachelectomy for early cervical cancer., Measurement and Main Results: A total of 7, 6, 6 and 3 patients undergone Type A, B, C and D cervical excision during RT, respectively. No significant differences in terms of age, BMI, surgical time and length of hospital stay were found according with different types of CE. Patients in Type D had, however, a significantly higher EBL, p =.006. Similar histology characteristics in terms of histology type, tumor grade and size, as well as lymph node count were observed among groups. Only grade 1-2 postoperative complications were noted in 9 patients. One local recurrence after Type B CE was treated with radical surgery plus chemoradiaton; while other patient after Type A CE relapsed with peritoneal carcinomatosis managed with chemotherapy., Conclusion: Different types of cervical excision that are here described should be used according to each case based on specific clinical factors., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Uterine myomas are the most common gynecologic benign tumor affecting women of childbearing age, and myomectomy is the main surgical option to preserve the uterus and fertility. During myomectomy for women with multiple myomas, it is advisable to identify and remove as many as possible to decrease the risk of future myomectomies. With deficient preoperative imaging, gynecologists are challenged to identify the location and size of myomas and the endometrium, which, in turn, can lead to uterine rupture during future pregnancies. Current conventional 2-dimensional imaging has limitations in identifying precise locations of multiple myomas and the endometrium. In our experience, we preferred to use 3-dimensional imaging to delineate the myomas, endometrium, or blood vessels, which we were able to successfully reconstruct by using the following imaging method. To achieve 3-dimensional imaging, we matched T2 turbo spin echo images to detect uterine myomas and endometria with T1 high-resolution isotropic volume excitation-post images used to detect blood vessels by using an algorithm based on the 3-dimensional region growing method. Then, we produced images of the uterine myomas, endometria, and blood vessels using a 3-dimensional surface rendering method and successfully reconstructed selective 3-dimensional imaging for uterine myomas, endometria, and adjacent blood vessels. A Web-based survey was sent to 66 gynecologists concerning imaging techniques used before myomectomy. Twenty-eight of 36 responding gynecologists answered that the 3-dimensional image produced in the current study is preferred to conventional 2-dimensional magnetic resonance imaging in identifying precise locations of uterine myomas and endometria. The proposed 3-dimensional magnetic resonance imaging method successfully reconstructed uterine myomas, endometria, and adjacent vessels. We propose that this will be a helpful adjunct to uterine myomectomy as a preoperative imaging technique in future studies., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Ovarian cysts are common in the reproductive age. Pathologic cysts such as endometriomas and dermoids often require surgical intervention if symptomatic. Laparoscopic cystectomy is the first-line treatment for these cysts and is associated with better pain control and less recurrence than drainage or cyst ablation procedures. There has been an emerging concern about the effect of ovarian cystectomy on ovarian reserve with some evidence of short-term and long-term reduction in ovarian reserve. Certain cyst characteristics (endometrioma pathology, large cyst size, bilateral presentation) are associated with a greater decline in ovarian reserve after cystectomy. The impact of surgery on ovarian reserve can be minimized by selecting the appropriate surgery for the patient, careful tissue handling, and limited use of electrosurgery. Patients should be counseled on the risks of surgery on reproductive potential, and the management plan should be individualized to the patient's symptoms and reproductive goals., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate our technique of mini-laparoscopic adnexectomy or salpingectomy at the time of total laparoscopic hysterectomy (TLH)., Design: Step-by-step video demonstration of our technique., Setting: The advantages of laparoscopic surgery have been widely recognized, including improved visualization and exposure, reduced operative trauma owing to smaller incisions and gentler tissue handling, and faster postoperative recovery. Continuing technological developments have allowed the use of smaller-caliber instruments while maintaining a high standard of surgical performance. Mini-laparoscopy requires the use of 3-mm or smaller ports. The main advantage of mini-laparoscopy is the reduced incision size, which can translate into a lower incidence of incision-related complications such as postoperative pain, infection, and trocar site herniation, along with superior cosmetic results. Today, in younger patients, prophylactic salpingectomy can be considered instead of adnexectomy, taking into account the well-known benefits of ovarian conservation. Prophylactic salpingectomy involves Fallopian tube removal for primary prevention of epithelial carcinoma of the fallopian tubes, ovaries, and peritoneum in women undergoing pelvic surgery for another indication. Other advantages of this intervention are the avoidance of hydrosalpinx (which affects ∼30% women after hysterectomy), the 7.8% lifetime risk of revision surgery [1], tubal infection, and benign and malignant Fallopian tube tumors. Finally, salpingectomy has no known physiological side effects, is safe and feasible, does not worsen surgical outcomes, does not significantly increase the operative time, and is not related to increased rates of intraoperative and postoperative complications or readmission., Interventions: The patient is a 44-year-old woman with a history of 2 previous cesarean sections with adenomyosis and endometriosis infiltration of the uterosacral ligaments. After discussion about the risks and benefits of ovarian conservation with prophylactic salpingectomy versus adnexectomy, the patient opted to preserve her ovaries. A TLH with partial removal of the uterosacral ligaments nodules and prophylactic bilateral salpingectomy was performed. To begin, the patient was placed in lithotomy position with Allen stirrups at an angle of approximately 100 degrees. Standard trocar placement was used. A 5- or 10-mm 0° scope was placed at the level of the umbilicus and three 3-mm skin incisions were made for accessory lower quadrant trocar placement: 2 lateral, approximately 3 cm medial to the anterior superior iliac spine, and 1 suprapubic, slightly higher than the line made by the lateral trocars, ensuring that the distance between this port and the camera trocar exceeded 8 cm. This triangulation of the accessory ports allowed for good ergonomics for the surgeon. The procedure continued with abdominopelvic cavity inspection and bilateral transperitoneal ureter identification and eventual adhesiolysis, and then the following steps: The instruments used were a 10-mm scope, a 3-mm bipolar forceps, 3-mm cold scissors, a 3-mm suction-irrigation device and 3-mm grasping forceps., Conclusion: Mini-laparoscopy is an alternative to classic laparoscopy associated with greater patient satisfaction. Prophylactic salpingectomy has proven to reduce the risk of ovary, peritoneal, and tubal epithelial carcinomas as well as benign tubal diseases, and does not significantly increase the operative time or the incidence of postoperative complications., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Preliminary data on the effects of prophylactic bilateral salpingectomy (PBS) show that postoperative ovarian function is preserved up to 3 months after surgery. The confirmation of PBS safety on ovarian function even many years after surgery is essential to reassure the medical community that this new strategy, recently proposed for the prevention of ovarian cancer, is at least able to avoid the risk of premature surgical menopause. We investigated whether the addition of PBS during total laparoscopic hysterectomy (TLH) causes long-term effects on ovarian function., Design: An observational study (Canadian Task Force classification II-3)., Setting: Department of Obstetrics and Gynecology, "Magna Graecia" University, Catanzaro, Italy., Patients: Seventy-nine patients who underwent TLH plus salpingectomy between September 2010 and September 2012 at our institution have been recalled to be submitted to ovarian reserve evaluation in February 2015. Eight of 79 women refused to participate in this follow-up study., Interventions: The ovarian age of PBS patients has been determined through OvAge (OvAge sr., Catanzaro, Italy), a statistical model that combines antimüllerian hormone, follicle-stimulating hormone, 3-dimensional antral follicle count, vascular index, flow index, and vascular flow index values. The control group consisted of a large population of 652 healthy women (with intact uterus and adnexa) previously enrolled to build the OvAge model. Comparisons between ovarian ages of PBS patients and the control group have been assessed by analysis of covariance linear statistical modeling., Measurements and Main Results: The main outcome measurement was the differences in the behavior within OvAge/age relation between PBS and control women. Descriptive statistics of those 71 enrolled PBS patients are the following: age, 49.61 ± 2.15 years; OvAge, 49.22 ± 2.57 years; follicle-stimulating hormone, 43.02 ± 19.92 mU/mL; antimüllerian hormone, 0.12 ± 0.20 ng/mL; 3-dimensional antral follicle count, 1.91 ± 1.28; vascular index, 2.80% ± 5.32%; flow index, 19.37 ± 5.88; and vascular flow index, 0.56 ± 1.12. Analysis of covariance disclosed that PBS and control women do not exhibit different behaviors (p = .900) within OvAge/age relation., Conclusion: According to our model, the addition of PBS to TLH in the late reproductive years does not modify the ovarian age of treated women up to 3 to 5 years after surgery., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Removal of retained adherent placental remnants (RAPRs) may be challenging using traditional 5Fr or 7Fr hysteroscopic grasping forceps because they are very small. This is particularly true when the retained placental remnant is large. This video demonstrates the advantages of using the Hysteroscopy Endo-Operative System (HEOS), a specially designed operative hysteroscope with a 13Fr working channel, to remove retained placental remnants., Design: Step-by-step explanation of the technique using videos and pictures (educative video) (Canadian Task Force Classification III)., Setting: Third Xiangya Hospital of Central South University, Hunan, China., Patient: A 32-year-old woman was diagnosed with RAPRs 5 weeks after the evacuation of retained placenta after a spontaneous abortion at 16 weeks' gestation. Gynecologic examination revealed an anterior 8-week uterus and no tenderness. Serum β-human chorionic gonadotropin was 150 mIU/L. Sonography revealed an irregular intrauterine mass, 3.5 cm × 3.5 cm × 3 cm in size., Intervention: Removal of RAPRs using HEOS (Sopro-comeg Company, Bordeaux, France)., Measurement and Main Results: The operation time was only 12 minutes. The RAPRs were removed completely and quickly in 1 procedure with no complications. The serum β-human chorionic gonadotropin titer normalized 1 week after the procedure. This study was approved by the institutional review board of the Third Xiangya Hospital of Central South University., Conclusions: When indicated, removal of RAPRs using HEOS is safe and simple because of its large and strong cold forceps. Additionally, it avoids electrical and thermal injury to the endometrium, which is particularly important in a population that wants to preserve fertility., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

We present the case of a young woman at 16 weeks' gestation who presented to a peripheral hospital with severe recurrent hemoperitoneum related to severe deep endometriosis infiltrating the left parametrium. She underwent 2 surgical open procedures in emergency, followed by pregnancy loss. Deep endometriosis infiltrated the rectum, the vagina, and the left parametrium, leading to stenosis of the left ureter and advanced destruction of the left kidney. Ovarian reserve was low with an antimullerian hormone level at .6 ng/mL. To improve endometriosis-related symptoms and preserve fertility, a laparoscopic conservative rectal and ureteral management was proposed with an aim to relieve symptoms, avoid further destruction of the left kidney, preserve the right splanchnic nerves and inferior hypogastric plexus, and enhance spontaneous conception. We performed a combined vaginal-laparoscopic approach that consisted of vaginal infiltration resection, adhesiolysis, rectal shaving, ureterolysis, and restoration of the permeability of the fallopian tubes. Seven months after surgery the patient spontaneously conceived and is doing well., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To show that in selected cases laparoscopic sacrocolpopexy can be used for the treatment of recurrent pelvic organ prolapse after vaginal mesh surgery., Methods: Step-by-step examination of the technique using an educative video. Institutional review board approval was obtained., Setting: The authors describe two clinical cases of treatment of recurrent pelvic organ prolapse, after a vaginal mesh surgery, using laparoscopic sacrocolpopexy., Patients: A 56-year old patient (para 3, gravida 2) presented with the sentation of bulging in the vagina. On physical examination, the patient had a grade 2-3 vaginal apical prolapse and a stage 4 rectocele. She had a slight mesh contraction but no vaginal extrusion and no pain were reported. Eleven years before, she had a vaginal total hysterectomy for pelvic organ prolapse correction and one year before she had a vaginal prolapse repair using a synthetic mesh. A laparoscopic sacrocolpopexy with bilateral ooforectomy was performed. The second case is of a 54-year old patient (para 2, gravida 2) that presented stress urinary incontinence. On physical examination, the patient had a grade 3 uterine prolapse and grade 2 cystocele. Eleven years before she had a vaginal prolapse repair using a synthetic mesh and a miduretral sling for stress urinary incontinence. Two years before, she had the miduretal sling removed for recurrent urinary infections and dysuria. A laparoscopic sub-total hysterectomy with salpingectomy and ovarian conservation, sacrocolpopexy and a Burch colposuspension was performed., Measurements and Main Results: The procedures and postoperative recovery were uneventful. No minor or major complications occurred. The patients were discharged three days after surgery., Conclusion: Laparoscopic sacrocolpopexy is a promising approach for the treatment of recurrent pelvic organ prolapse after vaginal mesh surgery. It appears to be feasible, safe, and effective., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Cervico-isthmic pregnancy is a rare and potentially life-threatening form of ectopic gestation in which the blastocyst implants in the uterine cervico-isthmus between the histological and anatomical internal os, followed by subsequent extension to the lower uterine segment. Early diagnosis may allow a conservative therapeutic approach that avoids catastrophic hemorrhage requiring hysterectomy. Here we report the case of a 43-year-old primigravida woman whose cervico-isthmic pregnancy complicated by massive hematometra was diagnosed at 6 weeks gestation by multimodal imaging and successfully treated by hysteroscopic resection, securing adequate hemostasis, after transcatheter arterial chemoembolization., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To assess the results of abdominal ultrasound-guided transvaginal myometrial core needle biopsy (CNB) for the definitive diagnosis of adenomyosis., Design: Retrospective study (Canadian Task Force classification II-3)., Setting: Private practice., Patients: A total of 1032 consecutive premenopausal women aged 22 to 53 years who had undergone myometrial CNB and uterine-preserving surgery to treat adenomyosis, which was preliminarily diagnosed on the basis of symptoms and ultrasonographic findings., Intervention: Transvaginal myometrial CNB under abdominal ultrasound guidance., Measurements and Main Results: The mean age of the 1032 patients was 41.4 years (range, 22-53 years); 61% were aged 40 to 49 years, and 33% were aged 30 to 39 years. The mean Pictorial Blood Loss Assessment Chart (PBAC) score was 271.1, and total pain score was 11.79. The mean anterior myometrial thickness was 2.79 cm (range, 0.7-8.7 cm), and the posterior myometrial thickness was 3.72 cm (range, 1.1-9.4 cm). A total of 2596 myometrial tissue cores were obtained from thickened myometrium via abdominal ultrasound-guided transvaginal myometrial CNB. At histopathologic examination the tissue cores demonstrated adenomyosis in 2167, myometrial hypertrophy in 343, and leiomyoma in 86. Patients were classified into a concordant group (adenomyosis only, adenomyosis plus hypertrophy, and adenomyosis plus leiomyoma; n = 951) and a discordant group (hypertrophy and leiomyoma; n = 81), depending on conformance between the pathologic result and the preliminary ultrasonographic diagnosis. The study showed a 92.26% concordance rate of adenomyosis between the transvaginal myometrial CNB and ultrasonographic diagnoses. The mean number of tissue cores in the discordant (n = 2.12) and concordant (n = 2.55) groups differed significantly (p < .05)., Conclusion: Abdominal ultrasound-guided transvaginal myometrial CNB can be used in the definitive diagnosis of clinically and/or sonographically suspected adenomyosis in patients undergoing uterine-preserving surgery. Future research should focus on improving the definitive diagnostic rate of adenomyosis by using transvaginal myometrial CNB., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Described is a novel surgical management of an unruptured interstitial pregnancy with preservation of the ipsilateral fallopian tube and uterine cornua. The patient was a 34-year-old woman, gravida 3, para 1, with an unruptured left interstitial pregnancy at 9 weeks' gestation, who desired preservation of fertility. The ectopic pregnancy was entirely removed via laparoscopically assisted hysteroscopy with a fertility-preserving surgical technique, with minimal blood loss, preservation of reproductive organs, restoration of anatomy, a patent ipsilateral fallopian tube, and expedient return to normal reproductive function. After the procedure, serial human chorionic gonadotropin levels were obtained until they were <5 mIU/mL. A hysterosalpingogram obtained 2 months after the procedure showed normal uterine and fallopian tube contour and bilateral tubal patency. We conclude that this laparoscopically assisted hysteroscopic technique is a safe and efficient fertility-preserving approach to management of an unruptured interstitial pregnancy., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate how endometriotic cystectomy and vaporization affect ovarian reserve after conservative surgery., Design: Prospective study (Canadian Task Force classification II-1)., Setting: Hokusetsu General Hospital., Patients: Ninety-nine women who underwent conservative surgery to treat endometriotic cysts from June 2011 to July 2013., Interventions: Vaporization with bipolar current was performed in nulligravid women, and cystectomy in those who had a child. In women with endometriotic cysts, bilateral cystectomy was performed in 28, bilateral vaporization in 15, unilateral cystectomy in 40, and unilateral vaporization in 16. In all patients, preoperative and postoperative serum anti-müllerian hormone (AMH) and follicle-stimulating hormone (FSH) concentrations at the early proliferative phase were assayed, and the change in concentrations was evaluated for each operation., Measurement and Main Results: In the bilateral cystectomy group, the mean (SD) postoperative FSH concentration (19.3 [21.8] IU/mL) was statistically higher than the preoperative concentration (9.0 [6.2] IU/mL) (p < .01). AMH significantly declined after all operations to treat endometriotic cysts, and the rate of decline in the AMH concentration was >50% compared with preoperative concentrations., Conclusion: Whether endometriotic cysts are unilateral or bilateral, both cystectomy and vaporization using bipolar current can lower ovarian reserve. Therefore, it is necessary to develop more effective surgical procedures to prevent ovarian damage., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate a technique of laparoscopic excision of uterine sacculation (niche) with uterine reconstruction., Design: Narrated video presenting a step-by-step explanation of a laparoscopic technique for excision of uterine sacculation (niche) with uterine reconstruction using a narrated video (Canadian Task Force classification III)., Setting: Laparoscopic excision of uterine sacculation (niche) is a fertility-sparing technique for use in a selected group of patients who do not respond to medical treatment and in whom definitive treatment via hysterectomy is not an option., Interventions: Laparoscopic excision of uterine sacculation (niche) is performed by excising the uterine defect after initial reflection of the uterovesical fold. The area of uterine defect is identified preoperatively using flexible hysteroscopy. Once the margins of the defect are identified laparoscopically, it is circumferentially excised. The uterine manipulator helps to identify the cervical canal. Reconstruction is performed using interrupted 1 Vicryl sutures using an extracorporeal technique for secure tissue apposition. An adhesion barrier is then applied around the reconstructed area., Conclusion: Excision of uterine sacculation (niche) with uterine reconstruction is a conservative surgical laparoscopic technique that should be considered in a selected group of patients in whom fertility sparing is desired and after medical therapy including progestogens, combined contraceptive pills, or the Mirena coil has failed to resolve symptoms., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)