Search

PURPOSE The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). METHODS GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL ( P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL. CONCLUSION Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

There are few data on complications with gender affirming surgery. The aim of this study was to assess peri- and postoperative complications of laparoscopic hysterectomy and mastectomy performed in a single sitting in transgender men. Assessment of intra- and postoperative complications in a series of 65 transgender men (mean age 27, range 18–47) undergoing concomitant mastectomy and laparoscopic hysterectomy with salpingo-oophorectomy. Mean operating time was 292 ± 47 min. Thirty-four (52%) patients experienced complications: 28 (41%) DINDO grade I, 0 DINDO grade 2, 6 (11%) DINDO grade III. The six grade 3 complications consisted of 5 hematomas requiring evacuation after mastectomy and 2 vaginal tears requiring transvaginal repair. Three patients were readmitted within 30 days, all for postoperative bleeding/hematoma. In transgender men, performing laparoscopic hysterectomy and mastectomy at a single sitting has a modest rate of perioperative complications, and may improve resource utilization. Supplementary Information The online version contains supplementary material available at 10.1007/s43032-021-00724-x.

ZusammenfassungDurch die Einführung der sog. Krebsfährtensuche mittels Kolposkopie, Zytologie und Histopathologie durch Ernst Navratil (1902–1977) im Jahr 1946 kam es zu einem markanten Aufschwung der Gynäkopathologie an der Grazer Univ.-Frauenklinik. Dieser Aufschwung war im Wesentlichen Fritz Bajardi (1918–2006) und Erich Burghardt (1921–2006) zu verdanken. Diese haben in der Zeit ihrer klinischen Tätigkeit durch ihre Zusammenarbeit wesentliche Erkenntnisse über die Pathogenese des Zervixkarzinoms geliefert. Erich Burghardt ist es im Besonderen zu verdanken, dass die in der Literatur verstreuten diesbezüglichen Publikationen in einem synoptischen Werk zusammengefasst wurden. Es werden die richtungsweisenden Forschungsergebnisse von Bajardi und vor allem von Burghardt im Lichte des heutigen Erkenntnisstandes diskutiert.

BACKGROUND: Colpectomy is a frequent part of gender-affirming surgery in transgender men. Urologic complications with these procedures can complicate and delay further management. Aim: We reviewed the rate of postoperative voiding dysfunction after colpectomy with urethral lengthening in transgender men. METHODS: We reviewed postoperative voiding in 47 transgender men (age, 19-50 years) who underwent colpectomy with urethral lengthening. Thirty-eight patients (81%) had undergone hysterectomy (36 total, 2 subtotal/supracervical) previously and 11 (23%) underwent concomitant hysterectomy or removal of the residual cervix (4 abdominal, 6 laparoscopic, 1 transvaginal). Colpectomy was done transvaginally by opening and developing laterally the vesicovaginal and rectovaginal spaces and then transecting the lateral vaginal attachments with bipolar vessel sealing. Urethral lengthening with an anterior vaginal flap was performed in the same procedure as colpectomy. A transurethral catheter was left in situ for 14 days postoperatively. Voiding dysfunction was defined as failure of spontaneous micturition after removal of the catheter at 14 days. RESULTS: 40/47 (85%) patients were able to void after catheter removal, 7 (15%) were not. Voiding dysfunction occurred in 3/11 (27%) patients undergoing concomitant hysterectomy or removal of a residual cervix and in 4/36 patients (11%) status post total hysterectomy. Voiding dysfunction persisted for a median of 3 months (2 days − 46 months). CONCLUSIONS: In this series voiding dysfunction developed in 15% of transgender men undergoing colpectomy with urethral lengthening and appeared to be more common in patients undergoing concomitant hysterectomy or removal of a residual cervix than in those status post hysterectomy. Patients should be counseled accordingly.

Study Objective Sacrocolpopexy (SCP) has become the standard procedure to correct uterovaginal prolapse in women, but techniques and approaches are not standardized. We report the results of the Austrian Sacrocolpopexy Registry, which aimed to collect data on surgical techniques and perioperative outcomes. Design The Austrian Urogynecology Working Group initiated a registry to assess surgical variability and perioperative safety of SCP. The study was performed at 14 centers (13 in Austria,1 in Switzerland). Institutional review board approvals were obtained. Patients Consecutive patients with symptomatic pelvic organ prolapse (POP). Interventions SCP in the course of routine POP treatment. Measurements and Main results Preoperative assessment included demographic data, clinical data on bladder, and bowel functions and POP-Q status. Surgical data included surgical approach (open, laparoscopic, robotic), type of mesh, depth of dissection, nerve sparing techniques, suture materials, uterus or cervix-sparing techniques, peritoneal closure, and concomitant surgeries. A total of 401 patients were recruited into the study. The mean age was 57 years (range: 26–84) and mean body mass index was 34. A total of 137 (34%) patients had undergone previous surgery for prolapse and in 264 cases SCP was the primary procedure. A total of 170 (42%) patients had undergone previous hysterectomy; For patients with uterus, SCP was performed with subtotal (n = 148) or total (n = 3) hysterectomy. A total of 285 (71%) SCPs were done laparoscopically, 102 (25%) robotically and 10 (3%) per laparotomy. The conversion rate from laparoscopy to abdominal surgery was 4.5%. Various meshes and suture materials were used and fixation techniques also varied widely. Four patients underwent reoperation within 30 days (2 trocar herniations, and 1 bowel obstruction, 1 compartment syndrome). One patient died of aortic dissection 7 days after SCP. Conclusions Most SCPs in this registry were performed laparoscopically, but there was considerable variation in surgical techniques. Perioperative morbidity appears modest.

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

Introduction Treatment for vulvodynia is challenging and a multidisciplinary approach is recommended. Aim To examine the effectiveness, safety and treatment satisfaction of vulvovaginal microablative laser treatment for vulvodynia. Methods Case study of women who received laser treatment as part of a multidisciplinary treatment program for vulvodynia. Subjective improvement was compared to a retrospective cohort of women treated for vulvodynia without LASER therapy. LASER treatment was offered to women with vulvodynia presenting to a gynecologic pain clinic of a tertiary university hospital. LASER treatments were performed with a microablative 2,940 nm Er:YAG LASER and potentially repeated after 1 month. Main outcome measures Change in local vulvar pain was assessed with cotton-swab tests and rated on a numeric rating scale (NRS). Treatment discomfort and short-term adverse events were recorded. The Freiburg Index of Patient Satisfaction was used to assess treatment satisfaction. Subjective symptom improvement was assessed with the Patient Global Impression of Improvement questionnaire. Results 35 women received at least 1 laser treatment, with overall mild treatment adverse effects (mean pain NRS 2.4 ± 1.9) and good treatment satisfaction (mean total score of 27.6 ±5.1; potential range 8–32). One month after last LASER treatment the pain NRS on vulvar cotton swab test improved from 6.1 ± 2.6 at baseline to 3.1 ± 2.6 (P < .001), and 74% of women (n = 26) reported symptom improvement. At 9–12 months follow-up 66% reported ongoing symptom improvement, with no significant difference to the control group of 32 women. Conclusion Microablative Er:YAG vulvovaginal LASER therapy appears safe and well accepted among vulvodynia patients, but there was no significant difference in symptom improvement compared to a control group.

Introduction/Background* Primary therapy planning, meaning primary surgery vs. neoadjuvant chemotherapy (NACT), in suspected advanced ovarian cancer is a professional and logistical challenge. Prompt diagnostic laparoscopy in such patients should confirm the diagnosis by frozen section, assess operability and thus, avoid unnecessary laparotomies. Methodology Retrospective evaluation of 130 patients who presented in 2016-2020 with suspected advanced ovarian cancer (peritoneal carcinomatosis, ascites on average 1,5L). Result(s)* In 2016-20, 82/130 patients (63%) underwent diagnostic laparoscopy; the others received either primary laparotomy, NACT, palliative chemotherapy, or best supportive care. 47% of the 82 patients were triaged to NACT, and 53% to primary surgery. The median time between initial presentation and laparoscopy was almost 8 days, the time from laparoscopy to first cycle of NACT was 14 days, and the time from laparoscopy to laparotomy was 15 days. The rate of R0 resections in patients with primary surgery after laparoscopy was 84%. Conclusion* Diagnostic laparoscopy seems to be an efficient measure in the workup and treatment planning of patients with suspected advanced ovarian cancer. The times between first presentation and laparoscopy as well as between laparoscopy and NACT or primary laparotomy need improvement.

Background Lower limb lymphoedema (LLL) is the most disabling adverse effect of surgical staging of pelvic lymph nodes. However, the lack of standardisation of volumetric LLL assessment hinders direct comparison between the studies and makes LLL reporting unreliable. The aim of our study is to report outcomes from a prospective trial that have implications for LLL assessment standardisation. Methods In the prospective international multicentre trial SENTIX, a group of 150 patients with stage IA1–IB2 cervical cancer treated by uterine surgery with bilateral sentinel lymph node biopsy was prospectively evaluated by objective LLL assessment, based on limb volume change (LVC) using circumferrential limb measurements and subjective patient-reported swelling. The assessments were conducted in six-month periods over 24 months post-surgery. Results Patient LVC substantially fluctuated in both positive and negative directions, which were comparable in frequency up to ±14% change. Thirty-eight patients experienced persistent LVC increase >10% classified as LLL, with nine months median time to onset. Some 34.2% of cases experienced onset later than one year after the surgery. Thirty-three patients (22%) experienced transient oedema characterised as LVC >10%, which resolved without intervention between two consequent follow-up visits. No significant correlation between LVC >10% and a patient-reported swelling was observed. Conclusions Given that we observed comparable fluctuations of the the lower-limb volumes after surgical treatment of cervical cancer in both positive and negative direction up to ±14%, the diagnostic threshold for LLL diagnosis based on LVC should be increased to >15% LVC. The distinction of transient oedema from persistent LLL requires repeated measurements. Also, as one-third of LLL cases are diagnosed >1-year post-surgery, a sufficient follow-up duration needs to be ensured. Patient-reported swelling correlated poorly with LVC and should only be used as an adjunct to objective LLL assessment. Trial registration: ClinicalTrials.gov : NCT02494063

Background: Breast cancer (BC) is with 30% among all cancers the most common cancer among women in Austria. Regarding therapy and management of BC, surgical treatments with resection and reconstruction play a crucial role. Breast-conserving therapy (BCT) represents a common procedure. However, mastectomy is still needed in about 30% of the patients with the diagnosis BC and as prophylactic surgery in indicated cases. Recently, autologous fat transfer (AFT, lipofilling) has been used to improve cosmesis in oncoplastic and reconstructive breast surgery. There is a gap of evidence for the oncological safety as well as the benefit for quality of life (QoL) in patients who had an AFT after the BC or prophylactic surgery. Material and methods: We assessed peri-and postoperative results, oncological outcomes and QoL in 55 patients undergoing AFT after BCT or mastectomy at our department between 2013 and 2018. QoL was assessed with the EORTC QLQ C30 and QLQ-BRECON23 questionnaires. Results: Overall, 55 patients (73 breasts) underwent AFT after BCT or mastectomy. 39 patients had a diagnosis of invasive BC (four bilateral) and six patients a diagnosis of DCIS. 24 mastectomies were done as prophylactic surgery. AFT was done in 22 cases with nipple sparing mastectomy (NSM), in 30 cases with skin sparing mastectomy (SSM), in 9 cases with simple mastectomy ± reconstruction and in 12 cases with BCT. The number of AFT sessions was 1-8 (mean 1.8). The injected fat volume per session was 30-390 ml. There were 10 (14%) complications: 3 hematomas (none needed reintervention), local inflammation requiring antibiotic therapy (n=3), formation of an oil cyst (n=1), and fat necrosis (n=3). In two cases of fat necrosis biopsy was performed to confirm the diagnosis. After a median follow-up of 34 months there was one recurrence (Paget´s disease after BC). QoL data will be presented at the meeting. Conclusion: Lipofilling after mastectomy for cancer appears to be oncologically safe. Our complication rate is relatively high, although additional surgical intervention (biopsy) was only necessary in two cases. Patients considering AFT should be informed about additional risk for biopsy, as well as other common complications. Citation Format: Bjelic-Radisic V, Oberfichtner K, Wurzer P, Trapp E, Rappl T, Reisniger J, Kamolz L-P, Tamussino K. Short-term outcomes and QoL following autologous fat transfer in oncoplastic and reconstructive breast surgery [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-07.

Purpose On January 1st, 2018, the ÖGZ (Austrian Society of Cytology) revised its cytological nomenclature to make it more similar to the 2015 Bethesda system. Following these changes, the Austrian Society of Gynecology and Obstetrics felt it necessary to revise the approach currently used in Austria to diagnose and treat CIN and to review the procedures to be followed when the quality of cytological specimens is unsatisfactory. It was not possible to adopt the German S3 guideline “Prevention of Cervical Cancer” in its entirety, because the Munich III gynecological cytology nomenclature used in Germany is not used in Austria. This made it necessary to compile a separate scientific opinion for Austria. Methodology The OEGGG worked together with the ÖGZ (Austrian Society for Cytology), AGO Austria (Austrian Working Group for Gynecological Oncology), the AGK (Colposcopy Working Group), and physicians representing gynecologists in private practice. The different scientific associations nominated representatives, who attended the various meetings. After an in-depth analysis of the recent literature, three meetings and numerous votes by telephone, we were able to achieve a consensus about the contents of this guideline. Recommendations The guideline provides recommendations for the diagnosis and treatment of CIN which take account of the gynecological cytology nomenclature used in Austria.

Fortschritte der chirurgischen und systemischen Therapien des Ovarialkarzinoms haben die Uberlebenszeiten von Patientinnen verlangert und den Fokus auf deren Lebensqualitat (LQ) erhoht. Die Berucksichtigung von Patient Reported Outcomes (PROs) als primare oder sekundare Endpunkte in klinischen Ovarialkarzinomstudien ist in den letzten Jahren deutlich angestiegen. Fur die Messung von PROs stehen standardisierte Instrumente zur Verfugung, die speziell fur Patientinnen mit Ovarialkarzinom entwickelt wurden. PRO-Instrumente sind mittels internetbasierter Erfassungsmethoden als ePROs verfugbar und weniger zeit- und kostenintensiv. Klinische Studienergebnisse mit PRO-Endpunkten haben in der Behandlung des Ovarialkarzinoms zur Veranderung des international anerkannten Therapiestandards gefuhrt. Auf Grundlage der Daten wurden Carboplatin plus Paclitaxel weltweit als neuer Standard der Primartherapie des fortgeschrittenen Ovarialkarzinoms festgelegt. Eine weitere Individualisierung der Therapie unter Berucksichtigung der LQ von Patientinnen konnte in der spaten Rezidivsituation des Ovarialkarzinoms ermoglicht werden. Neben klinischen Studien finden PROs zunehmend auch in der klinischen Routine Eingang. Die Mehrheit onkologischer Patienten befurwortet die routinemasige Erfassung der LQ. PRO-Daten geben wichtige Information uber die subjektive Auswirkung der Erkrankung und der Therapie auf die LQ der Patientinnen, konnen fur gemeinsame Therapieentscheidungen herangezogen werden und Behandlungsoptionen an die Bedurfnisse der Patientinnen anpassen.

Introduction/Background Usual type vulvar intraepithelial neoplasia (u-VIN) is a premalignant condition of the squamous epithelium of the vulva caused by persistent infection with high-risk human papillomavirus (HPV), and classified as high grade squamous intraepithelial lesion (HSIL). Surgery is the standard treatment, but recurrences occur in about 50% of patients. Imiquimod, a topical immune response modifier, has been shown to be effective, but has not been compared to surgery. The aim of this study was to compare the effectiveness and acceptance of primary imiquimod treatment with surgical treatment of HSIL/VIN. Methodology This was a multicentre randomised controlled trial of women with histologically confirmed HSIL/VIN II-III. Exclusion criteria were clinical suspicion of microinvasion, a history of vulvar cancer, severe dermatosis, pregnancy, and any active treatment for VIN within the previous three months. Patients were randomized to primary topical treatment or surgery at a ratio of 1:1 and stratified by unifocal or multifocal disease. Treatment with imiquimod was self-administered for a period of 4 months with possible extension. Surgical treatment was performed according to the standard procedures of the trial site. Clinical assessment, colposcopy, vulvar punch-biopsy and HPV-test (cobas®, Roche) were performed at baseline and 6 months. Clinical follow-up, including questionnaires on health-related quality-of-life, was conducted at 12 months. Results Between June 2013 and January 2020 a total of 110 patients were enrolled at six hospitals in Austria. Mean age was 51 years (SD 16, range 19 -82) with 57% being postmenopausal. 66 patients (61%) had a history of previous HPV related anogenital HSIL or genital warts, and 21 women (19%) had received previous treatment for VIN. 85 women (78%) presented with unifocal and 24 (22%) with multifocal VIN, and 56 women (51%) reported local symptoms. 40 women (37%) had a history of current or past smoking. 56 women were allocated to primary treatment with imiquimod, and 54 women to primary surgery. Surgical treatment was performed by local excision in 22 cases (14 cold-knife, 6 electrosurgical), by laser destruction (n= 27), or combined (n=3). 12-months follow-up will be completed in January 2021. Conclusion The results of this clinical trial will show whether imiquimod is a safe and effective alternative to surgery in women with HSIL/VIN2-3. Disclosures The study was funded by the Austrian Science Fund (FWF) and the Austrian Association for Gynecologic Oncology (AGO). The study medication Aldara 5% cream was provided by Meda Pharma GmbH. The authors have no conflict of interest.

BackgroundOptimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice.MethodsQuality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives.ResultsFifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes.DiscussionImplementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Introduction/Background Introduction: GROINSS-V II investigated whether radiotherapy is a safe alternative for inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). Methodology Methods: In GROINSS-V II, a prospective multicentre phase II trial, patients were included with early-stage squamous cell carcinoma (SCC) of the vulva (diameter Results From December 2005 until October 2016, 1552 eligible patients were registered. SN-metastasis occurred in 324/1552 (21%) patients. After 54 months of inclusion the stopping-rule for SN-positive patients was activated; interim analysis showed an increased risk for groin recurrence in case of SN-metastasis >2 mm and/or extranodal extension (ENE). After amendment of the protocol only patients with SN-micrometastasis ≤2 mm received radiotherapy, while those with SN metastasis >2 mm underwent IFL (with radiotherapy if >1 metastasis or ENE). Final analysis after ≥2 years of follow-up revealed six isolated groin recurrences in 157 patients with a SN-micrometastasis (3.8%). Four could not be considered radiotherapy failures: two developed recurrence in the contralateral (SN-negative) groin, two refused radiotherapy. Twenty-eight patients did not get radiotherapy (2 recurrences;7.1%). Among 129 patients who received radiotherapy to the groin(s) only two isolated groin recurrences were diagnosed (1.6%: 95%CI:0–3.8%). The combination of radiotherapy with SN was associated with minimal toxicity: 5/118(4.2%) grade 3 toxicity, no grade 4 or 5 toxicity. In 38/1222 SN-negative patients (3.1%: 95%CI:2.1–4.1%) isolated groin recurrences were diagnosed with clear protocol violations in 6 patients: incomplete treatment of the groin (n=3); primary tumor >4cm (n=1); not all SNs visualized on the lymphoscintigram removed (n=2). After exclusion of these protocol violations an isolated groin recurrence rate of 2.6% (95%CI:1.7–3.5%) was observed. Conclusion Radiotherapy to the groins is a safe alternative for IFL in patients with SN metastasis ≤2 mm, with minimal toxicity. We further established the safety of omitting IFL in patients with SCC of the vulva 2 mm, radiotherapy with a total dose of 50Gy was no safe alternative for IFL; dose escalation and/or chemoradiation should be investigated in these patients. Disclosure Funded by Dutch Cancer Society.

Introduction: Vulvodynia and chronic pelvic pain are common but underdiagnosed chronic gynecologic pain syndromes. Insufficient knowledge regarding prevalence, typical pain patterns and ass...

Objective To assess whether there is any association between the implantation of synthetic polypropylene mesh slings for the treatment of stress urinary incontinence (SUI) and risk of cancer. Methods We performed a nationwide cohort study based on the general female population in Sweden. All women entered the observational period as unexposed on January 1, 1997, and contributed person-time as unexposed unless they underwent a midurethral sling procedure for SUI, after which they contributed person-time as exposed until first occurrence of any cancer, death, emigration, or end of the observational period (December 31, 2009). Occurrence of primary cancer was ascertained from the Cancer Register. Hazard ratios (HRs) with 95% CIs were calculated by Cox proportional hazards regression. Results The final study population included 5,385,186 women, including 20,905 exposed, encompassing a total of 44,012,936 person-years at risk. Other than an inverse association with rectal cancer (HR 0.5, 95% CI 0.3-0.8), there were no significant differences in risk between exposed and unexposed women for pelvic organ cancers including ovarian (HR 0.8, 95% CI 0.5-1.2), endometrial (HR 1.1, 95% CI 0.8-1.4), cervical (HR 0.4, 95% CI 0.2-1.0), bladder, and urethra (HR 0.7, 95% CI 0.4-1.2). No significant association was observed between exposed women and primary cancer in any organ system when compared with unexposed women. The relative risk for cancer after exposure showed little variation over time except for an inverse overall correlation within the first 4 years of surgery (HR 0.7, 95% CI 0.7-0.8). The incidence rates per 100,000 person-years (95% CIs) for exposed vs unexposed women were 20.5 (14.3-29.5) vs 21.0 (20.6-21.5) for rectal cancer, 25.5 (18.4-35.3) vs 19.8 (19.4-20.2) for ovarian cancer, 65.0 (53.0-79.8) vs 33.1 (32.6-33.7) for endometrial cancer, 5.7 (2.8-11.3) vs 11.9 (11.6-12.2) for cervical cancer, and 19.1 (13.1-27.8) vs 13.3 (13.0-13.7) for bladder and urethra cancer. Conclusion Our results suggest that midurethral polypropylene sling surgery for SUI is not associated with an increased cancer risk later in life.

Ovarian, tubal, and peritoneal carcinomas primarily affect the peritoneal cavity, and they are typically diagnosed at an advanced tumor stage (Foley, Rauh-Hain, del Carmen in Oncology (Williston Park) 27:288–294, 2013). In the course of primary surgery, postoperative tumor residuals are, apart from the tumor stage, the strongest independent factors of prognosis (du Bois, Reuss, Pujade-Lauraine, Harter, Ray-Coquard, Pfisterer in Cancer 115:1234–1244, 2009). Due to improved surgical techniques, including the use of multi-visceral procedures, macroscopic tumor clearance can be achieved in oncological centers, in most cases (Harter, Muallem, Buhrmann et al in Gynecol Oncol 121:615–619, 2011). However, to date, it has not been shown that peritoneal carcinomatosis is, per se, an independent factor of prognosis or that it excludes the achievement of tumor clearance. Several studies have shown that a preceding drug therapy in peritoneal carcinomatosis could positively influence the overall prognosis (Trimbos, Trimbos, Vergote et al in J Natl Cancer Inst 95:105–112, 2003). In relapses of ovarian carcinoma, studies have shown that peritoneal carcinomatosis is a negative predictor of complete tumor resection; however, when it is possible to resect the tumor completely, peritoneal carcinomatosis does not play a role in the prognosis (Harter, Hahmann, Lueck et al in Ann Surg Oncol 16:1324–1330, 2009). PIPAC is a highly experimental method for treating patients with ovarian, tubal, and peritoneal cancer. To date, only three studies have investigated a total of 184 patients with peritoneal carcinomatosis (Grass, Vuagniaux, Teixeira-Farinha, Lehmann, Demartines, Hubner in Br J Surg 104:669–678, 2017). Only some of those studies were phase I/II studies that included PIPAC for patients with different indications and different cancer entities. It is important to keep in mind that the PIPAC approach is associated with relatively high toxicity. To date, no systematic dose-finding studies have been reported. Moreover, no studies have reported improvements in progression-free or overall survival associated with PIPAC therapy. Randomized phase III studies are required to evaluate the effect of this therapy compared to other standard treatments (sequential or simultaneous applications with systemic chemotherapy). In cases of ovarian, tubal, and peritoneal cancer, PIPAC should not be performed outside the framework of prospective, controlled studies.

Summary Background To assess emotional distress, anxiety and stress reactions in breast cancer (BC) patients before the follow-up visits. Study design Between September 2009 and December 2011 a total of 284 patients completed the BC-psychosocial assessment screening scale (PASS) and a questionnaire about their views of follow-up after treatment for BC. Results Of the patients 64% reported low level of distress on the BC-PASS. The mean scores on the physical well-being scale was 5.3, the satisfaction/sense of coherence scale 7.4, and the emotional distress scale 8.1. Women rated mammography as the most important component (71%), followed by breast ultrasound (63%) and the consultation with the physician (60%). Of the patients 94% were satisfied with the current follow-up regimen. Conclusions In this series BC patients were satisfied with their aftercare. Mammography was thought to be the most important component of aftercare. Patient-reported outcomes should be taken into account when planning follow-up.

Introduction: Most serous ovarian cancers are now thought to originate in the fallopian tubes. This has raised the issue of performing incidental salpingectomy (also called elective, opportunistic, prophylactic or risk-reducing salpingectomy) at the time of benign gynecologic surgery or cesarean section. We conducted an online survey to ascertain the policies regarding incidental salpingectomy in Austria in late 2014. Material and Methods: All 75 departments of obstetrics and gynecology in public hospitals in Austria were surveyed for their policies regarding incidental salpingectomy at benign gynecologic surgery or cesarean section. Results: Sixty-six of 75 surveyed departments completed the questionnaire, resulting in a response rate of 88 %. Overall, 46 of 66 (70 %) units reported offering or recommending incidental salpingectomy at benign gynecologic surgery, 12 units (18 %) did not, and eight units (12 %) did not have a consistent policy. Salpingectomy was the preferred method for surgical sterilization, including sterilization at the time of cesarean section (71 % and 64 % of units, respectively). Conclusions: Incidental (elective, opportunistic, prophylactic, risk-reducing) salpingectomy is now widely offered at benign gynecologic surgery and cesarean section in Austria. Evidence for the role of the fallopian tubes in the origin of serous pelvic cancer has led to changes in clinical practice.

Objective To determine how many FIGO (International Federation of Obstetrics and Gynecology) member societies have statements regarding opportunistic (incidental, prophylactic, risk-reducing) salpingectomy at the time of benign gynecologic surgery and to categorize statements as positive, negative or ambivalent. Study design The websites of the 130 FIGO member societies were searched for statements on opportunistic salpingectomy. We looked for separate statements and statements embedded in other documents such as clinical guidelines as well as statements by national societies of gynecologic oncology. If nothing was found on the websites we contacted societies by Email or fax. Results As of early 2018, 13 FIGO member societies representing 14 countries have statements regarding opportunistic salpingectomy. Nine were separate, stand-alone statements, four were embedded in other documents. Nine of the 13 statements (from Canada, Finland, U.S.A., Great Britain, Australia and New Zealand, Denmark, Austria, Turkey, and Japan) support consideration of opportunistic salpingectomy in appropriate women and four (from Germany, Sweden, Norway, and France) are ambivalent; there are no statements recommending against opportunistic salpingectomy. Conclusion In 2018 only a small minority of FIGO members have statements on opportunistic prophylactic salpingectomy. These statements are ambivalent or supportive, none is negative.

Background Most serous ovarian cancers are now understood to originate in the fallopian tubes. Removing the tubes (salpingectomy) likely reduces the risk of developing high‐grade serous ovarian cancer. Numerous gynaecological societies now recommend prophylactic (or opportunistic) salpingectomy at the time of gynaecological surgery in appropriate women, and this is widely done. Salpingectomy at the time of non‐gynaecological surgery has not been explored and may present an opportunity for primary prevention of ovarian cancer. Methods This study investigated whether prophylactic salpingectomy with the intention of reducing the risk of developing ovarian cancer would be accepted and could be accomplished at the time of elective laparoscopic cholecystectomy. Women aged at least 45 years scheduled for elective laparoscopic cholecystectomy were recruited. They were counselled and offered prophylactic bilateral salpingectomy at the time of cholecystectomy. Outcome measures were rate of accomplishment of salpingectomy, time and procedural steps needed for salpingectomy, and complications. Results A total of 105 patients were included in the study. The rate of acceptance of salpingectomy was approximately 60 per cent. Salpingectomy was performed in 98 of 105 laparoscopic cholecystectomies (93·3 per cent) and not accomplished because of poor visibility or adhesions in seven (6·7 per cent). Median additional operating time was 13 (range 4–45) min. There were no complications attributable to salpingectomy. One patient presented with ovarian cancer 28 months after prophylactic salpingectomy; histological re‐evaluation of the tubes showed a previously undetected, focal serous tubal intraepithelial carcinoma. Conclusion Prophylactic salpingectomy can be done during elective laparoscopic cholecystectomy., Serous ovarian cancer is now understood to arise in the fallopian tubes. Prophylactic salpingectomy to reduce the risk of ovarian cancer is widely recommended at gynaecological surgery in appropriate women. This article explores prophylactic salpingectomy at the time of non‐gynaecological surgery. No harm, benefit still unclear

AimTo examine the position of the TVT-O sling 10 years postoperatively and its association with outcome.MethodsA total of 124 patients who received a TVT-O sling at two centers in 2004 and 2007 were invited for follow-up. The position of the sling on perineal ultrasound was described relative to the bladder neck and the lower margin of the pubic symphysis at rest and on Valsalva. Objective cure was defined as a negative cough stress test at 300 ml. Subjective cure was evaluated with the Kings´ Health Questionnaire (KHQ), Incontinence Outcome Questionnaire (IOQ), Female Sexual Function Index Questionnaire (FSFI) and the Patient Global Impression of Improvement score (PGII).Results78 of 124 patients (57%) were available for follow-up 10 years after surgery. I Eleven (14%) had undergone reoperation and were excluded. Tapes were visualized in the remaining 67 (54%) women. The subjective and objective cure rates in this sub-cohort were 67% (45/67) and 77% (52/67), respectively. In these 67 women the mean distances from the bladder neck to the proximal edge of the tape (BNTD) during Valsalva maneuver were significantly higher in cured women compared to the not-cured women (11.2 vs. 9.4mm). The distance between tape and urethra (TUD) was significantly lower in cured vs. not cured patients (2.6 vs. 4.1mm). All women with a TUD of >5mm (n = 5) were incontinent. Tape position was not associated with overactive bladder symptoms.ConclusionsTape position near the bladder neck and large distance to the urethra is associated with incontinence 10 years after TVT-O.

Purpose Suburethral tapes are a standard surgical treatment for stress urinary incontinence. The aim of the study was to evaluate subjective and objective cure rates 10 years after a tension-free vaginal tape-obturator procedure. Materials and Methods All 124 patients who underwent the tension-free vaginal tape-obturator procedure at a total of 2 centers in 2004 and 2005 were invited for followup. Objective cure was defined as a negative cough stress test at 300 ml. Subjects completed KHQ (King's Health Questionnaire), IOQ (Incontinence Outcome Questionnaire), FSFI (Female Sexual Function Index Questionnaire) and PGI-I (Patient Global Impression of Improvement). Results Overall, 55 of 112 women (49%) who were alive were available for clinical examination and 71 (63%) completed the questionnaires. The objective cure rate in the 55 women examined clinically was 69%, 22% were not cured and 9% (5) had undergone reoperation for recurrent or persistent stress urinary incontinence. Treatment was counted as having failed in these 5 women for study purposes. Subjective cure was reported by 45 of 71 women (64%). Three patients (5%) had vaginal tape extrusion at the time of clinical examination. Extrusion in all of them was small and asymptomatic, and did not require treatment for a cumulative extrusion rate of 7%. Six women (9%) had undergone reoperation for tension-free vaginal tape-obturator associated complications and 18 (26%) experienced de novo overactive bladder. Conclusions Subjective and objective cure rates 10 years after the tension-free vaginal tape-obturator procedure were 69% and 64%, respectively. The vaginal extrusion rate in this study was slightly higher than in other series but major long-term complications appeared to be rare.

Objective. In 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. Methods. From2000 until 2006 GROINSS-V-I included 377 patientswith unifocal squamous cell carcinoma of the vulva (T1

Background: Genetic testing is of prognostic and predictive importance in patients with ovarian cancer and breast cancer. The best explored mutations are those of the BRCA 1 and BRCA2 genes, and the result of BRCA testing impacts treatment and prophylactic options. Data on other breast-cancer-associated genes are accumulating. Methods: All patients who underwent genetic counseling and testing for BRCA 1 and BRCA 2 between 2007 and 2019 at the Medical University of Graz were reviewed. If BRCA testing was negative patients were offered panel testing for other breast and ovarian cancer associated genes including ATM, PETEN, RAD50, RAD51D, RAD51C, TP53, STK11, ATM, NBN, CDH, MSH6, MSH2, MLH1, CHEK2, PALB2, BRIP1, SMO, PETEN, SMO. Results: In total 1905 patients were counseled for genetic testing between 2007 to 2019. In 292 patients (mean age 53yrs) panel gene testing was performed. 114 (39%) of these 292 BRCA-negative patients (55 with breast cancer, 24 with ovarian cancer) had a pathogenic variant (n=32) or a mutation of unknown significance (n=82). The most common pathogenic variant occurred in the CHEK2 gene (n=15). Interpretation: In this series approximately one third of high-risk patients who tested negative for a BRCA mutation had a mutation of unknown significance and/or pathogenic mutation in gene panel testing. This indicates that genetic panel testing should be considered more frequently. Citation Format: Elisabeth Katharina Trapp, Michael Speicher, Jochen B Geigl, Vassiliki Kolovetsiou-Kreiner, Julia Reisinger, Josef Haas, Edgar Petru, Karl Tamussino, Gunda Pristauz. Multigene panel analysis in breast and ovarian cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-03-09.

The working group recommends against contralateral prophylactic mastectomy (CPM) in women with breast cancer without a family history or genetic predisposition with unilateral breast cancer. This is based on the low risk of developing contralateral breast cancer, the lack of a survival benefit, the increased risk of surgical complications, and the lack of benefit on quality of life.

Background: Sentinel lymph node biopsy has become a standard of care in the treatment of patients with early breast cancer, but clinical guidelines continue to be vague on details of the procedure. We were interested in the results of our 2-day protocol, which includes delayed lymphoscintigraphy at 18 h. Methods: We reviewed the results of preoperative lymphoscintigrams in patients undergoing surgery for breast cancer. Lymphoscintigraphy was performed 2 h after periareolar injection of 4 × 37 MBq 99mTc nanocolloid (early lymphoscintigraphy) and 18 h following injection (delayed lymphoscintigraphy). The early results were compared with the late results. Results: A total of 238 lymphoscintigraphies were performed in 232 patients (6 bilateral). At 2 h, ≥1 sentinel nodes were visualized in 154/238 (65%) cases; in 84 (35%), no sentinel node was visualized. Delayed lymphoscintigraphy visualized a sentinel node in 40 of 76 (53%) cases with no visualization at 2 h and failed to show a sentinel node in 36 (47%) of these cases (in 8 cases, no delayed lymphoscintigram was obtained). Conclusions: Delayed lymphoscintigraphy was useful in about 50% of the breast cancer patients in whom immediate scintigraphy failed to demonstrate a sentinel lymph node.

BackgroundDespite significant advances in the screening, detection, and treatment of preinvasive cervical lesions, invasive cervical cancer is the fifth most common cancer in European women. There are large disparities in Europe and worldwide in the incidence, management, and mortality of cervical cancer.ObjectiveThe European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) jointly develop clinically relevant and evidence-based guidelines in order to improve the quality of care for women with cervical cancer across Europe and worldwide.MethodsThe ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of cervical cancer (23 experts across Europe). To ensure that the guidelines are evidence based, the current literature identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 159 international reviewers, selected through ESGO/ESTRO/ESP and including patient representatives.ResultsThe guidelines cover comprehensively staging, management, and follow-up for patients with cervical cancer. Management includes fertility sparing treatment; stage T1a, T1b1/T2a1, clinically occult cervical cancer diagnosed after simple hysterectomy; early and locally advanced cervical cancer; primary distant metastatic disease; cervical cancer in pregnancy; and recurrent disease. Principles of radiotherapy and pathological evaluation are defined.

Aims Our aim was to evaluate, in a second data analysis of the prospective randomized controlled trial conducted by Austrian Urogynaecology Working Group, the effect of age, BMI and parity at the time of surgery on short- and long-term outcomes of women primarily treated for SUI (stress urinary incontinence) with midurethral slings. Methods In the original study 554 patients received randomly a retropubic (TVT) or a transobturator midurethral (TVT-O) sling procedure. 480 (87%) and 277 (50%) patients were available for a follow-up efficacy evaluation at 3 months and 5 years respectively. Results Higher age and BMI at surgery appear to lead to a larger probability to have a positive stress test 5 years after surgery, but not after 3 months. Older patients seem to have a worse perception of improvement 5 years after surgery as compared to younger ones, as described by the PGI-I score. Age and BMI do not affect significantly the quality of life of women surgically treated for SUI, as reflected by the results of King´s Health Questionnaire. Parity does not seem to have any effect on objective and subjective surgical outcomes. Conclusions Higher age and BMI at surgery have a detrimental influence on the objective cure rate at 5 years after midurethral sling surgery; higher age also has a negative influence on subjective long-term outcomes. However, these demographic parameters do not influence significantly the quality of life of patients after anti-incontinence surgery. Parity does not show any significant influence on success rate of midurethral sling.

All types of hysterectomy are more challenging in the obese patient. This applies to the technical aspects of access and getting the operation done, to the comorbidities encountered in these patients, and to the increased risk of postoperative complications.

Aims The Patient Global Index of Severity (PGI-S) and the Patient Global Index of Improvement (PGI-I) are global impression questionnaires developed in English and validated in women with stress urinary incontinence (SUI). This validation study tested the psychometric properties of German-language versions of the two questionnaires in German-speaking women with SUI. Methods The German-language PGI-S and PGI-I were psychometrically tested and validated using the SF-12 questionnaire, the Kinǵs Health Questionnaire (KHQ), clinical parameters, incontinence episode frequency and pad use in 311 patients before and 3 months after receiving a TVT-O or TVT tape for SUI. Results At baseline and 3 months postoperatively there was a positive correlation between PGI-S response categories and clinical parameters, IEF and pad use, and nearly all KHQ subscales. There were no correlations between response categories of PGI-S at baseline and PGI-I at 3 months and the SF-12 scales PCS-12 and MCS-12. Conclusion Our results demonstrated good psychometric properties of the German-language PGI-S and PGI in German-speaking women with SUI.

Introduction Rates and routes of hysterectomy have implications for quality, costs and training. This study analyzed rates of benign hysterectomy and surgical approaches for benign hysterectomy in Austria from 2002 to 2014. Material and Methods This was a population-based retrospective observational study of coding data from all acute care hospitals (public and private) in Austria. Main outcome measures were numbers of women undergoing hysterectomy for benign indications in Austria per year and the route of hysterectomy for benign indications. Results The number of benign hysterectomies performed per year declined from 10 675 in 2002 to 7747 in 2014, a decline of 27%. The use of vaginal hysterectomy was stable (53% and 47%, respectively). Use of laparoscopic techniques increased (5% in 2002, 32% in 2014) whereas use of abdominal hysterectomy decreased (41% and 20%, respectively). Conclusions Numbers of benign hysterectomies performed per year in Austria declined substantially between 2002 and 2014. Use of vaginal hysterectomy was stable at about 50%, whereas increased use of laparoscopic techniques was associated with lower rates of open hysterectomy.

Objective Recent evidence has supported the concept that epithelial ovarian cancer (EOC) arises from the cells of the fallopian tube or endometrium. This study investigated current practice in Japan with respect to performing opportunistic bilateral salpingectomy (OBS) during gynecological surgery for benign disease for Ovarian Cancer Prevention. Methods We mailed a questionnaire to 767 hospitals and clinics, comprising 628 accredited training institutions of the Japan Society of Obstetrics and Gynecology (JSOG), Japan Society of Gynecologic Oncology (JSGO), or Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) and 139 private institutions with at least one JSGOE-certified licensed gynecologic laparoscopist. Results Among the 767 institutions, 444 (57.9%) provided responses, including 91 (20.6%) that were both JSGOE and JSGO accredited, 71 (16.0%) that were only JSGO accredited, 88 (19.8%) that were only JSGOE accredited, and 194 (43.7%) that were unaccredited. It was found that awareness and performance of OBS largely depended on the JSGO and/or JSGOE accreditation status. OBS was only performed at 54.0% of responding institutions and just 6.8% of the institutions were willing to participate in randomized controlled trials to validate this method for reducing the incidence of ovarian cancer. Conclusion The JSOG Gynecologic Tumor Committee will announce its opinion on salpingectomy for ovarian cancer prevention to all JSOG members and will develop a system for monitoring the number of OBS procedures in Japan.

Background/Definition of the Problem: In recent years, postoperative management has changed towards rapid mobilisation, early oral feeding and rapid rehabilitation (known as Fast-Track or Enhanced Recovery Concepts). This study analysed the postoperative length of stay after vaginal hysterectomy in 3 different periods of time. Material and Methods: In the period October 2011 – September 2012, 75 patients underwent vaginal hysterectomies (± adnexectomy); another 114 vaginal or laparoscopic hysterectomies with additional operations (e.g. prolapse surgery and incontinence surgery) and malignancies were not included. The time periods August 1995 – July 1996 (n = 50) and October 1996 – September 1997 (n = 96) served as a comparison. Reducing the length of stay was not an explicit goal. Results: The median postoperative stay was shortened from 7 (5–9) to 5 (3–15) or 3 (0–5) days (p

We conducted a prospective randomized controlled noninferiority trial to compare objective and subjective outcomes of retropubic tension-free vaginal tape (TVT) with those of transobturator tape (TVT-O) as primary treatment for stress urinary incontinence (SUI) in women. The study was conducted at 25 gynecology units in Austria and Germany; regional and academic hospitals participated. A total of 569 patients were randomly assigned to undergo TVT or TVT-O. A total of 480 patients (85 %) were examined at 3 months. A negative cough stress test with stable cystometry to 300 ml was seen in 87 % of patients after TVT and in 84 % after TVT-O; 64 % and 59 % of patients, respectively, reported no pad use, and 88 % of patients in both groups considered themselves much or very much better on the Patient Global Impression of Improvement (PGI-I) scale. Quality of life (QoL) as assessed with the SF-12 Health Survey, Kings’ Health Questionnaire, (KHQ), and EuroQol-5D (EQ-5D) was significantly improved in both arms, with no differences between arms. There were no significant differences in postoperative pain or complications. Results of this trial demonstrate noninferiority between TVT and TVT-O with regard to postoperative continence and QoL and suggest little difference in perioperative problems (ClinicalTrials.gov NCT 00441454).

Aims To compare outcomes of the retropubic versus the transobturator tension-free vaginal tape (TVT vs TVT-O) at 5 years. Methods A total of 569 women undergoing surgery for primary stress incontinence were randomized to receive a retropubic or a transobturator tensionfree vaginal tape (TVT or TVT-O). Follow-up at 5 years included clinical examination, urodynamic studies and quality of life. The primary outcome measure was continence defined as a negative cough stress test at a volume of 300 mL. Secondary outcomes included urodynamic parameters, complications and quality of life.ClinicalTrials.gov (NCT 0041454). Results Three hundred and thirty-one patients (59%) were evaluated at 5 years (277 were seen, examined and completed questionnaires; 54 only completed questionnaires). No significant differences were seen in rates of a negative cough stress test (83% vs 76%, respectively), urodynamic parameters and complications. Quality-of-life improved significantly in both groups, without significant differences between the groups. Erosion rates were 5.2% and 4.5%, and reoperation rates were 4.1% and 3.2% respectively. Conclusions At 5 years, subjective and objective results after TVT and TVT-O are stable and similar, without statistical significant differences between the procedures. Major long-term problems appear rare.

[This corrects the article DOI: 10.1371/journal.pone.0209668.].

BIwastoldIhadthebestprocedureformycondition.IsittrueI could have had vaginal surgery without mesh?^ This ques-tionwasposedbythe43-year-oldwomannowfacingtheneedfor adhesiolysis and trachelectomy due to pelvic pain andcyclic bleeding two years after undergoing laparoscopicsupracervical hysterectomy and mesh sacrocervicopexy forstage 3 uterine prolapse (Fig. 1).Theclaimofsuperiorityofsacrocolpopexy(SC)overotherpelvic organ prolapse (POP) procedures was initiated by theresults ofthree randomizedcontrolledtrials(RCTs)involvinga total of 287 patients comparing abdominal SC (ASC) andsacrospinous ligament fixation (SSLF) published in 1996,1998and2004[1–3].Thesestudiesreportedsuperioranatom-ic outcomes with ASC when compared with SSLF, but alsoshowed higher short-term morbidity with ASC. The claim ofsuperiorityofASCoverSSLFwasfurtherreinforcedwiththepublication ofthe first CochranesystematicreviewofsurgeryforPOPpublishedin2004,whichsummarizedthefindingsofthe three previously mentioned studies stating Babdominalsacral colpopexy was better than vaginal sacrospinouscolpopexy in terms of a lower rate of recurrent vault prolapseand less dyspareunia, but the trend towards a lower re-operation rate for prolapse following abdominalsacrocolpopexy was not statistically significant^ [4]. SincetheseinitialRCTscomparingASCwithSSLF,severalsystem-atic reviews have shown the same findings of superior ana-tomic outcomes associated with ASC compared with SSLF[4–11]. These reviews reinforce the perception that there is alarge body of evidence supporting ASC as the best option fortreating POP.Laparoscopic SC (LSC) and robot-assisted SC have beendeveloped to reduce the short-term morbidity associated withASC [12, 13]. Many surgeons consider these less invasiveapproaches to SC (and variations such as sacrocervicopexy)equivalenttoASCintermsofanatomicoutcomeleadingthemtoclaimthatLSCandroboticSCapproachesarenowthebestoptions for treating POP. The most recent Cochrane reviewpublished in 2013 concludes Bsacral colpopexy has superioroutcomes to a variety of vaginal procedures includingsacrospinous colpopexy, uterosacral colpopexy andtransvaginal mesh^ implyingthatall formsofSC are superiorto all other surgical options for treating apical prolapse [9].A close look at the current literature, however, reveals thatthereareactuallyveryfewlevel1studiesfromwhichtoderivesuch a bold conclusion concerning SC compared with otheroptionsfortreatingPOP.OnlytwostudiescomparingSCwithother procedures have been added to the Cochrane reviewover the past decade and both of these are controversial. Oneis a trial comparing LSC with total vaginal mesh (TVM) thatshowedsuperiorityofLSCcomparedtoTVM[14].Thestudyis controversial because the reported success rate for TVMwassignificantlylowerthantherateachievedbyotherauthorsand because of this low rate, LSC was reported as superior.The other is an abstract of a trial comparing ASC withuterosacral ligament suspension (USLS) that showed superi-ority of ASC, but this study is yet to be published as a fullpeer-reviewed article limiting the ability to assess the qualityand potential confounding factors affecting the results [15]. Itistheadditionofthesetwocontroversial studieswhich result-edinthechangeofwordingintheCochraneReviewsummaryfrom the more specific statement that BASC is superior to