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Background: Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned., Objectives: To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair., Search Strategy: MEDLINE and Embase databases were searched from inception to January 2023., Selection Criteria: We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded., Data Collection and Analysis: A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI)., Main Results: Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups., Conclusions: No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors., (© 2024 International Federation of Gynecology and Obstetrics.)

To compare the in-hospital opioid and non-opioid analgesic use among women who underwent robotic-assisted hysterectomy (RH) vs. open (OH), vaginal (VH), or laparoscopic hysterectomy (LH). Records of women in the United States who underwent hysterectomy for benign gynecologic disease were extracted from the Premier Healthcare Database (2013-2019). Propensity score methods were used to create three 1:1 matched cohorts stratified in inpatients [RH vs. OH (N = 16,821 pairs), RH vs. VH (N = 6149), RH vs. LH (N = 11,250)] and outpatients [RH vs. OH (N = 3139), RH vs. VH (N = 29,954), RH vs. LH (N = 85,040)]. Opioid doses were converted to morphine milligram equivalents (MME). Within matched cohorts, opioid and non-opioid analgesic use was compared. On the day of surgery, the percentage of patients who received opioids differed only for outpatients who underwent RH vs. LH or VH (maximum difference = 1%; p < 0.001). RH was associated with lower total doses of opioids in all matched cohorts (each p < 0.001), with the largest difference observed between RH and OH: median (IQR) of 47.5 (25.0-90.0) vs. 82.5 (36.0-137.0) MME among inpatients and 39.3 (19.5-66.0) vs. 60.0 (35.0-113.3) among outpatients. After the day of surgery, fewer inpatients who underwent RH received opioids vs. OH (78.7 vs. 87.5%; p < 0.001) or LH (78.6 vs. 80.6%; p < 0.001). The median MME was lower for RH (15.0; 7.5-33.5) versus OH (22.5; 15.0-55.0; p < 0.001). Minor differences were observed for non-opioid analgesics. RH was associated with lower in-hospital opioid use than OH, whereas the same magnitude of difference was not observed for RH vs. LH or VH., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH)., Methods: A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs)., Results: Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878]., Conclusions: High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use., (© 2023. The Author(s).)

Objective: This study aimed to assess the effects on oncologic outcomes of intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer., Data Sources: A systematic literature search was performed by an expert librarian in multiple electronic databases from inception to January 31, 2023., Study Eligibility Criteria: We included all studies in the English language that compared oncologic outcomes (recurrence-free, cause-specific, or overall survival) between endometrial cancer patients who underwent total laparoscopic or robotic hysterectomy for endometrial cancer with vs without the use of an intrauterine manipulator. Studies comparing only peritoneal cytology status or lymphovascular space invasion were summarized for completeness. No selection criteria were applied to the study design., Methods: Four reviewers independently reviewed studies for inclusion, assessed their risk of bias, and extracted data. Pooled hazard ratios with 95% confidence intervals were estimated for oncologic outcomes using the random effect model. Heterogeneity was quantified using the I 2 tests. Publication bias was assessed by funnel plot and Egger test., Results: Out of 350 identified references, we included 2 randomized controlled trials and 12 observational studies for a total of 14 studies and 5,019 patients. The use of an intrauterine manipulator during hysterectomy for endometrial cancer was associated with a pooled hazard ratio for recurrence of 1.52 (95% confidence interval, 0.99-2.33; P=.05; I 2 =31%; chi square P value=.22). Pooled hazard ratio for recurrence was 1.48 (95% confidence interval, 0.25-8.76; P=.62; I 2 =67%; chi square P value=.08) when only randomized controlled trials were considered. Pooled hazard ratio for overall survival was 1.07 (95% confidence interval, 0.65-1.76; P=0.79; I 2 =44%; chi square P value=.17). The rate of positive peritoneal cytology or lymphovascular space invasion did not differ using an intrauterine manipulator., Conclusion: Intrauterine manipulator use during hysterectomy for endometrial cancer was neither significantly associated with recurrence-free and overall survival nor with positive peritoneal cytology or lymphovascular space invasion, but further prospective studies are needed., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other., Material and Methods: We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, vs closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up., Results: Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] vs 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ., Conclusions: Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease., Study Design: An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications., Results: Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p < 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p < 0.001) were found as independent risk factors for major postoperative complications., Conclusions: Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy., Data Sources: PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered., Methods of Study Selection: The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence., Tabulation, Integration, and Results: A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88)., Conclusion: There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To assess predictors of recurrence following laparoscopic radical hysterectomy (LRH) for apparent early stage cervical cancer (CC)., Methods: This is a retrospective multi-institutional study reviewing data of consecutive patients who underwent LRH for FIGO 2009 stage IA1 (with lymphovascular space invasion (LVSI)), IA2 and IB1(≤4 cm) CC, between January 2006 and December 2017. The following histotypes were included: squamous, adenosquamous, and adenocarcinoma. Multivariable models were used to estimate adjusted odds ratio (OR) and corresponding 95% CI. Factors influencing disease-free survival (DFS) and disease-specific survival (DSS) were also explored., Results: 428 patients were included in the analysis. With a median follow-up of 56 months (1-162) 54 patients recurred (12.6%). At multivariable analysis, tumor size (OR:1.04, 95%CI:1.01-1.09, p = .02), and presence of cervical residual tumor at final pathology (OR: 5.29, 95%CI:1.34-20.76, p = .02) were found as predictors of recurrence; conversely preoperative conization reduced the risk (OR:0.32, 95%CI:0.11-0.90, p = .03). These predictors remained significant also in the IB1 subgroup: tumor size: OR:1.05, 95%CI:1.01-1.09, p = .01; residual tumor at final pathology: OR: 6.26, 95%CI:1.58-24.83, p = .01; preoperative conization: OR:0.33, 95%CI:0.12-0.95, p = .04. Preoperative conization (HR: 0.29, 95%CI: 0.13-0.91; p = .03) and the presence of residual tumor on the cervix at the time of surgery (HR: 8.89; 95%CI: 1.39-17.23; p = .01) independently correlated with DFS. No independent factors were associated with DSS., Conclusions: In women with early stage CC the presence of high-volume disease at time of surgery represent an independent predictor of recurrence after LRH. Conversely, preoperative conization and the absence of residual disease at the time of surgery might play a protective role., Competing Interests: Declaration of Competing Interest All authors do not have any personal or financial conflict of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: This multicentric prospective phase II study aimed to investigate the feasibility, safety, and efficacy of percutaneous-assisted laparoscopic hysterectomy in terms of perioperative outcomes, feasibility, VAS score, and cosmetic outcomes., Study Design: Between May 2015 and October 2017, 382 patients were considered eligible for minimally invasive percutaneous-assisted laparoscopic hysterectomy using Percuvance™, Percutaneous Surgical System - PSS, TELEFLEX ltd. Among them, 80 patients (20.9 %) met the inclusion criteria and were enrolled in the study. The coordinator center was the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Enrolled patients underwent total percutaneous-assisted laparoscopic hysterectomy ± bilateral salpingo-oophorectomy ± nodal assessment., Results: The median age was 52 (range, 32-80) years, and the median body mass index was 25 kg/m 2 (range, 16-37). Thirty-five patients (43.8 %) had previous surgery. A median operative time of 82.5 (range, 40-190) minutes and a median estimated blood loss of 50 (50-500) mL were registered. We observed 1 (1.3 %) intraoperative complication. The median time to discharge was 1 (range, 1-5) day. Patients were extremely satisfied with the scar evaluation and postoperative pain control. Five (6.25 %) complications were recorded within 30 days after surgery., Conclusion: Percutaneous-assisted technique for extrafascial hysterectomy achieved excellent results in terms of feasibility, safety, and efficacy, even in complex cases and advanced surgical procedures. Therefore, the technique appears to balance the limitations and advantages of minimal surgical invasiveness and standard approach efficacy., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Study Objective: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire., Design: Secondary analysis of a prospective randomized controlled trial., Setting: Three academic research centers., Patients: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included., Interventions: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications., Measurements and Main Results: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively)., Conclusion: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.)., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the feasibility of percutaneous approach, we prospectively compared our experience in percutaneous-assisted hysterectomy (PSS-H) with that in a series of laparoscopic hysterectomies (LPS-Hs)., Methods: In this multicentric cohort study, from May 2015 to October 2017, 160 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive surgery (MIS): 80 patients received PSS-H and 80 LPS-H. In each group, 30 cases of low-/intermediate-risk endometrial cancer were enrolled. For both groups, we documented preoperative outcomes, postoperative pain, and cosmetic outcomes., Results: No statistically significant differences were noted in baseline characteristics or operative time. We observed significant differences in estimated blood loss: median of 50 cc (PSS-H) and 100 cc (LPS-H) (p = 0.0001). In LPS-H, we reported 4 (5.0%) intraoperative complications and 1 (1.3%) in PSS-H. Thirty-day complications were 4 (5%) in PSS-H and 11 (13.8%) in LPS-H (p = 0.058). No significative differences were found in visual analog scale score, despite a relevant disparity in cosmetic outcome (p = 0.0001). For oncological cases, the 2 techniques had comparable intra- and postoperative outcomes and oncological accuracy., Conclusions: In this study, we reported that PSS-H is comparable to LPS-H for intra- and perioperative outcomes and postoperative pain, while PSS-H seems to be superior in cosmetic outcomes and patient satisfaction. PSS-H may represent a valid alternative in ultra-MIS for benign gynecological conditions and low-/intermediate-risk endometrial cancer., (© 2020 S. Karger AG, Basel.)

A hysterectomy for enlarged uteri is considered a challenge for gynaecologic surgeons, due to the limit of exposure to surgical spaces. Our objective is to investigate the different variables that may have an impact on the risk of conversion to open surgery. This is a retrospective cohort study consisting of 133 women who were submitted to surgery for uterine fibroids and who underwent total hysterectomy by laparoscopic approach attempt. The median uterus weight was 622 grams (range 301-3882) and the median maximum diameter of the bigger fibroid was 74 mm (range 33-148). We registered 13 (9.8%) cases of conversion to laparotomy. Minor and major post-operative complications were recorded in 4 (3%) and in 4 (3%) cases, respectively. After multivariable analysis, the surgeon's experience (OR: 0.24; 95% CI: 0.06-0.94, p  = .027) and a maximum diameter of the biggest fibroid ≥10 cm (4.7; 1.39-15.87; p  = .046), but not the uterus weight were associated with the risk of conversion to open surgery. IMPACT STATEMENT What is already known on this subject? Laparoscopic procedures for enlarged uteri are well described in literature; however, the only parameters that have been studied for the success of a laparoscopic procedure have been the uterus weight and the surgeon's experience. What do the results of this study add? This study aimed to value all the possible variables related to the successful of laparoscopic procedures; in fact, we investigated not only the uterine weight, but in our multivariate analysis, the position of the fibroids, the trocar's setting, etc. were analysed. What are the implications of these findings for clinical practice and/or further research? This study reported novel data about the feasibility of laparoscopic hysterectomy for enlarged uteri. In opposition to the literature, the uterine weight is not a predictive value for laparotomic conversion. Moreover, we discussed the possible reasons of our novel findings. It opens new perspective to create a predictive value of laparoscopic feasibility for the different types of enlarged uteri.

Objective: To investigate the safety, feasibility and oncological adequacy of the Percutaneous Surgical System - PSS in a consecutive series of low-risk endometrial cancer staging., Study Design: From May 2015 to April 2017, we prospectively performed 30 consecutive percutaneous staging for low/intermediate risk endometrial cancer (FIGO stage IA G1-G2, IB G1-G2, IA G3). All patients were divided in two different groups on the basis of surgical procedure received: Group A included patients submitted to radical Class A hysterectomy and bilateral salpingo-oophorectomy; Group B concerned patients that received a lymph nodal assessment also., Results: The time needed to install percutaneous instruments and suprapubic trocar was 4 min. (range 2-10). The recorded median operative time (OT) was 80 min. (range 65-120) for Gr.A and 143 min. (range 107-190) for Gr.B, in which the median time of lymph nodal assessment was 55 min. (range 20-76). The median time for hysterectomy was 60 min. (range 40-110) in all cases. Lymph nodal assessment was performed in 14 (46.6%) cases: 7 sentinel node mapping, 7 pelvic lymphadenectomy. No intraoperative complications or LPS/LPT conversions were recorded. Median discharge time was 2 days (range 1-4), 5 patients were discharged in 3rd post-op day, and only 1 patient was discharged in 4th day for fever. All patients conveyed high satisfaction with the cosmetic results. A progressive overall reduction of pain perception was observed at 24 h after surgery. Median follow-up was of 14 months (range 12-36), no recurrences have been detected., Conclusions: PSS seems to be a feasible approach for endometrial cancer staging. Larger experiences and prospective comparative studies are important to assess our assumptions and further investigate the real benefits of percutaneous surgical system., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Study Objective: To investigate the feasibility, safety, and short-term outcomes of robotic surgery (RS) for gynecologic oncologic indications (cervical, endometrial, and ovarian cancer) in elderly patients, especially women age 65 to 74 years (elderly group [EG]) compared with women age ≥75 years (very elderly group [VEG])., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: Catholic University of the Sacred Heart, Rome, Italy., Patients: Between May 2013 and April 2017, 204 elderly and very elderly patients underwent RS procedures for gynecologic malignancies., Results: The median age was 71 years (range, 65-74 years) in the EG and 77 years (range, 75-87 years) in the VEG. The incidence of cardiovascular disease was higher in the VEG (p = .038). The EG and VEG were comparable in terms of operative time, blood loss, and need for blood transfusion. Almost all (98.5%) of the patients underwent total/radical hysterectomy, 109 patients (55.6% of the EG vs 48.3% of the VEG) underwent pelvic lymphadenectomy, and 19 patients (10.5% of the EG vs 6.7% of the VEG) underwent aortic lymphadenectomy. A total of 7 (3.4%) conversions to open surgery were registered. Only 3 patients required postoperative intensive care unit admission. The median length of hospital stay was 2 days in each group. A total of 11 patients (5.6%) had early postoperative complications. Four patients (2.8%) in the EG and 2 patients (3.3%) in the VEG experienced grade ≥2 complications. At the time of analysis, median follow-up was 18 months (range, 6-55 months). Eleven patients (5.6%) experienced disease relapse, 2 (1%) died of disease, and 3 (1.5%) died of cardiovascular disease., Conclusions: This study demonstrates the feasibility, safety, and good short-term outcomes of RS in elderly and very elderly gynecologic cancer patients. No patient can be considered too old for a minimally invasive robotic approach, but a multidisciplinary approach is the best management pathway; efforts to reduce associated morbidity are essential., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Background: Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event., Objective: The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial., Study Design: Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy., Results: After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence., Conclusion: Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To compare 3-mm minilaparoscopy and standard 5-mm laparoscopy for sentinel lymph node (SLN) detection in apparent early-stage endometrial cancer (EC)., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: Two academic research centers., Patients: Consecutive women with apparent early-stage EC who underwent surgical staging with SLN detection between November 2015 and April 2016., Interventions: The surgical approach was a total laparoscopic extrafascial hysterectomy plus bilateral salpingo-oophorectomy and SLN detection. Systematic lymphadenectomy was performed in selected cases. In all patients, SLN detection was performed with cervical injection of indocyanine green and the use of an optical camera with a near-infrared high-intensity light source for detection of fluorescence imaging. All patients who underwent a minilaparoscopic approach (using one 5-mm scope and three 3-mm ancillary trocars) have been enrolled at the University of Insubria, whereas at the San Gerardo Hospital, standard laparoscopy was performed with one 10-mm scope and three 5-mm ancillary trocars., Measurements Ad Main Results: A total of 38 patients were enrolled, including 15 (39.5%) in the 3-mm group and 23 (60.5%) in the 5-mm group. No between-group differences were found in terms of demographic and tumor characteristics. Bilateral SLNs were detected in 73.3% of the patients in the 3-mm group and in 73.9% in the 5-mm group. Operative time, blood loss, hemoglobin drop, hospital stay, and the incidence and severity of complications were similar in the 2 groups. One patient (4.3%) in the standard 5-mm group had a positive SLN result (a micrometastasis in the left external iliac SLN). No positive SLNs were detected in the 3-mm group., Conclusion: Minilaparoscopic SLN biopsy appears to be a promising and feasible technique for EC staging. Further research is warranted to investigate the possible benefits of 3-mm instruments in this specific setting., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To present a large single-center series of hysterectomies for uteri ≥1 kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications., Design: A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2)., Setting: An academic research center., Patients: Consecutive women who underwent hysterectomy for uteri ≥1 kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished., Interventions: Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy)., Measurements and Main Results: Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50-360] vs 85 [range, 35-240] minutes, p = .014). The estimated blood loss (150 [range, 0-1700] vs 200 [50-3000] mL, p = .04), postoperative hemoglobin drop, and hospital stay (1 [range, 1-8] vs 3 [range, 1-8] days, p < .001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p = .015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p = .04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio = 0.42; 95% confidence interval, 0.19-0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients., Conclusion: In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1 kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Purpose: Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. Our aim has been to analyze perioperative details and complications of TLH in women with vs. women without endometriosis., Methods: Consecutive women who underwent TLH for endometriosis (endometriosis group) were compared with consecutive patients who had TLH for other conditions (controls) in terms of perioperative outcomes. Patients in the endometriosis group were analyzed, according to the severity of the disease., Results: One-hundred and twelve women in the endometriosis group, 29 (25.9 %) with minimal-mild, and 83 (74.1 %) with moderate-severe stage disease (rAFS score), respectively, were compared with 572 controls. Conversion rate was 0.8 vs. 0.5 % (P = 0.51), and median operative time was 75 vs. 55 min (pxxx = x) in the endometriosis group vs., Controls: Intraoperative complications were similar between groups (P = 0.56). Postoperative complications occurred in 10 (12.3 %) women in the endometriosis group vs. 12 (3.3 %) among the controls (P = 0.002). The severity of complications according to Clavien-Dindo classification system was higher in the endometriosis group (Clavien-Dindo >2: 7.5 vs. 1.9 %). The risk of organ lesions, urinary lesions, postoperative complications, and severe adverse events was significantly higher in women with moderate-severe endometriosis vs., Controls: No differences between patients with minimal-mild endometriosis and controls were found., Conclusion(s): TLH in the case of endometriosis is associated with longer operative time and an almost fourfold increase in the risk and severity of complications compared with controls. In particular, the adjunctive risk of adverse events is specific for moderate/severe-stage disease but not for minimal/mild endometriosis.

Unlabelled: STUDY, Objective: To evaluate perioperative outcomes and complications of laparoscopic hysterectomy (LH) in women with giant uteri (≥1.5 kg) compared with open abdominal hysterectomy (AH), which is considered the reference., Design: A retrospective analysis of prospectively collected data (Canadian Task Force Classification II-2)., Setting: An academic research center., Patients: All consecutive women who underwent hysterectomy for uteri weighing ≥1500 g (total = 51) between 2000 and 2015 were analyzed. Twenty-seven (53%) patients had been scheduled for the laparoscopic approach (LH), whereas 24 (48%) had been scheduled for AH., Interventions: Hysterectomy ± mono/bilateral salpingo-oophorectomy., Main Outcome Measures: Perioperative details, incidence, severity, and type of complications were analyzed according to surgical approach (AH vs LH). We also evaluated the trends over time in terms of perioperative outcomes., Results: AH was associated with a shorter operative time (97.5 vs 160 minutes, p = .004) compared with LH. Blood loss (200 vs 225 mL, p = .21) and the decrease in postoperative hemoglobin (-1.2 vs -1.1, p = .89) were similar between AH and LH. Intra- and postoperative complications were similar between the 2 groups; however, hospital stay was significantly shorter in the LH group (median = 3 days vs 1 day, p < .001). A significant trend toward a progressive increase in the use of the minimally invasive approach was registered through the years (p = .001). Parallel to this increase, we observed a significant reduction in terms of length of stay. Moreover, a decrease in the total number of complications, mainly because of a decrease in the rate of early minor events, was observed through the years., Conclusions: Our experience shows that LH can be considered a feasible procedure, even in cases of uteri ≥1.5 kg, with significant advantages over open surgery in terms of postoperative hospital stay., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to compare site and time to recurrence in patients affected by early stage cervical cancer (CC) treated with laparoscopy radical hysterectomy (LRH) versus abdominal radical hysterectomy (ARH)., Methods: This retrospective study was conducted in a university teaching, tertiary referral center hospital. We included patients undergoing either LRH or open ARH to treat CC., Results: One hundred fifty patients were included, 82 submitted to LRH and 68 submitted to ARH. Baseline characteristics of the 2 groups were comparable, except for body mass index higher in ARH group. Patients undergoing LRH experienced less blood loss (100 vs 400 mL, P < 0.0001), less lymph nodes removed (20 vs 31, P = 0.001), and shorter recovery (4 vs 8 days, P = 0.0005) in comparison with the ARH group. No significant differences were found regarding recurrence rate (9 vs 13, P = 0.17) and time to recurrence (8 vs 17 months, P = 0.066) between LRH and ARH group.Sites of recurrence were also comparable between the 2 groups: 2/9 versus 2/13 (P = 1) local recurrence, 4/9 versus 8/13 (P = 0.66) pelvic recurrence, 4/9 versus 7/13 (P = 1) distant recurrence in LRH and ARH groups, respectively. The most frequent sites of recurrence were pelvic and distant (44.4%) in LRH group and pelvic (61.5%) in ARH group., Conclusions: Our data demonstrate that early stage CC can be treated with LRH with similar recurrence rates and patterns in comparison with ARH, reassuring its continuing clinical use.

Objective: To evaluate the impact of obesity on the outcomes of surgical treatment for endometrial cancer in general and also comparing laparoscopic and open abdominal approach., Design: Retrospective case-control study (Canadian Task Force classification II-1)., Setting: Obstetrics and Gynecology Department, University of Insubria, Varese, Catholic University of the Sacred Heart, Rome, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, and Sant'Orsola-Malpighi Hospital, Bologna, Italy., Patients: Data of consecutive patients who underwent surgery for endometrial cancer in 4 centers were reviewed. Univariate and multivariable analyses were performed. Adjustment for potential selection bias in surgical approach was made using propensity score (PS) matching., Interventions: Laparoscopic or open surgical treatment for endometrial cancer., Measurements and Main Results: A total of 1266 patients were included, including 764 in the laparoscopy group and 502 in the open surgery group. A total of 391 patients (30.9%) were obese, including 238 (18.8%) with class I obesity, 89 (7%) with class II obesity, and 64 (5.1%) with class III obesity. The total number of complications, risk of wound complications, and venous thromboembolic events were higher in obese women compared with nonobese women. Blood transfusions, incidence/severity of postoperative complications, and postoperative hospital stay were significantly higher in the open surgery group compared with the laparoscopy group, irrespective of obesity. These differences remained significant in both multivariable analysis and PS-matched analysis. The percentage of patients who received lymphadenectomy declined significantly in patients with BMI ≥40 in both the laparoscopy and open surgery groups. Conversions from the initially intended minimally invasive approach to open surgery were 1.1% to 2.2% for women with BMI <40, but increased in those with BMI ≥40 (8.6%; p = .05). PS analysis showed a lower complication rate, shorter hospital stay, and greater likelihood of receiving lymphadenectomy in obese women in the laparoscopic group., Conclusion: Laparoscopy for endometrial cancer retains its advantages over open surgery, even in obese patients. However, operating on obese patients can be challenging regardless of the surgical approach taken, especially in cases of morbid adiposity., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Lymphatic mapping and sentinel lymph node (SLN) biopsy have been proposed as a safer and less morbid approach than full lymphadenectomy for patients with early endometrial cancer (EC), through either cervical or corporeal dye injection.1 (-) 4 The advantage of mini-laparoscopy is a further reduction in the overall surgical trauma for the patient. This video aims to show the feasibility of SLN biopsy using a 3-mm mini-laparoscopic approach., Methods: A 56-year-old woman with grade 2 endometrioid EC underwent mini-laparoscopic pelvic SLN detection plus extrafascial total hysterectomy and bilateral salpingo-oophorectomy (TLH-BSO). A two-sided superficial and deep cervical injection of indocyanine green (2 mL diluted to 1.25 mg/mL) was used for inoculation before the procedure. A 5.8-mm 0° optical camera with a near-infrared high-intensity light source for detection of fluorescence imaging was inserted through the umbilicus. Two ancillary 3-mm trocars were inserted suprapubically. The procedure was accomplished using only 3-mm instruments., Results: Neither intraoperative complications nor conversion to conventional laparoscopy or open surgery occurred. The operative time was 60 min, and the estimated blood loss was 50 mL. SLN was detected bilaterally, and removal of the two identified nodes was achieved through meticulous dissection and preservation of the surrounding structures followed by TLH-BSO. No postoperative complications were registered, and the patient was discharged 24 h after surgery. An SLN ultrastaging exam was negative, and the final pathology showed a International Federation of Gynaecology and Obstetrics (FIGO) stage 1A G2 EC with a 2/21-mm myometrial invasion., Conclusion: Mini-laparoscopic SLN detection plus TLH-BSO is a feasible procedure that guarantees minimal surgical trauma to selected patients with early EC.

Background: Laparoendoscopic single-site surgery and minilaparoscopy (ie, the use of 3-mm instruments) represent two of the most recent advances in ultraminimally invasive surgery. We have combined these two techniques and transvaginal cuff closure to develop a technique for the performance of single-incision, transumbilical, minilaparoscopic hysterectomy., Technique: The complete endoscopic detachment of the uterus from its supports and vessels is performed using only two 3-mm minilaparoscopic trocars, both inserted in the umbilicus, with the aid of a uterine manipulator. The procedure was completed with transvaginal extraction of the uterus and transvaginal closure of the vaginal cuff., Experience: We performed 20 minilaparoscopic single-site hysterectomies. One (5%) conversion to conventional minilaparoscopic hysterectomy was needed as a result of adhesions. No intraoperative or postoperative complications occurred and all women were discharged home within 30 hours after surgery. Postsurgical pain (measured with a 0-10 visual analog scale administered by an independent observer postoperatively) was very low: 2 (1-3), 2 (1-3), and 0 (0-2) at 1, 3, and 8 hours postoperatively, respectively., Conclusion: Single-site total minilaparoscopic hysterectomy using only two 3-mm ports inserted through the umbilicus is feasible and further reduces the incisional trauma of surgery.

Objective: The aim of the study was to compare surgery-related outcomes between laparoscopic (LH) and vaginal (VH) hysterectomy, performed for benign uterine disease (other than pelvic organs prolapse) in obese women., Study Design: Data of consecutive obese (BMI≥30) patients undergoing LH and VH, between 2000 and 2013, were compared using a propensity-matched analysis. One hundred propensity-matched patient pairs (200 patients) undergoing LH (n=100) and VH (n=100) represented the study group., Results: Baseline demographic characteristics were similar between groups. Patients undergoing LH experienced similar operative time (87.5 (25-360) vs. 85 (25-240)min; p=0.28), slightly lower blood loss (100 (10-3200) vs. 150 (10-800)ml; p=0.006) and shorter length of hospital stay (1 (1-5) vs. 2 (1-5) days; p<0.001) than women undergoing VH. There was no statistically significant difference between LH and VH in complication rate (3% for VH vs. 10% for LH; OR: 3.4; 95%CI: 0.95-13.5; p=0.08). At multivariable analysis complication rates increased as BMI increase (OR: 1.01 (1.00-1.02) for 1-unit increase in BMI; p=0.05). Independently, LH correlated with reduced hospital stay (OR: 0.63 (95%CI: 0.49-0.82); p=0.001) and complication rates (OR: 0.91 (95%CI: 0.85-0.97); p=0.01)., Conclusions: In obese women affected by benign uterine disease LH and VH should not be denied on the basis of the mere BMI, per se. In this setting, LH upholds effectiveness of VH, improving postoperative outcomes. However, complication rate increases as BMI increase, regardless surgical route., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Hysterectomy for enlarged uteri is a surgical challenge. Our aim was to compare perioperative outcomes, cosmesis, and postoperative quality of life following laparoscopic hysterectomy for large uteri using minilaparoscopic 3-mm versus conventional laparoscopic 5-mm instruments., Subjects and Methods: We prospectively enrolled women with a uterus between 16 and 20 weeks of gestation at the preoperative examination. These patients underwent laparoscopic procedures using either 3-mm (minilaparoscopy group) or 5-mm (standard laparoscopy group) instruments. Five months after surgery, patients were called back to fill out the validated Italian translation of the Short Form 12-item Health Survey. Data about the cosmetic outcome of the procedure were also collected, using a Numeric Rating Scale (NRS) from 0 to 10., Results: Seventy-eight women were included (27 in the 3-mm and 51 in the 5-mm groups). Perioperative characteristics were comparable between groups. The median uterus weight was 575 (range, 440-1050) g and 550 (400-1000) g in the 3-mm and 5-mm groups, respectively. No minilaparoscopic procedure was converted to standard 5-mm or to an open approach. One (2%) conversion to open abdominal surgery was needed in the conventional laparoscopy group. A better subjective cosmetic outcome was found in the 3-mm (NRS, 9.7 ± 0.4) versus the 5-mm (NRS, 8.9 ± 1.2) group (P=.01). Postoperative quality of life was comparable between groups., Conclusions: Minilaparoscopic hysterectomy is feasible, even in the case of an enlarged-size uterus. Moreover, it is associated with a better cosmetic outcome, compared with conventional laparoscopy.

Objective: The present study aimed to evaluate surgical operation-related outcomes of laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for the treatment of benign uterine diseases, other than pelvic organ prolapse, in women aged 65 years or older., Methods: Data of women who underwent LH and VH between 2000 and 2013 were compared using propensity-matched analysis. Postoperative complications were graded according to the Accordion Severity Grading. Martin criteria were applied to improve the quality of complications reporting., Results: The study group included 40 propensity-matched participant pairs (80 women) who underwent VH and LH. No significant differences in baseline characteristics were observed between groups. A trend toward longer median operative time was observed in the LH group, in comparison with the VH group (75 [range, 20-340] vs 60 [range, 30-140] min; P = 0.09), whereas LH correlated with shorter hospital stay and lower blood loss in comparison with VH (P < 0.05). One intraoperative complication occurred during VH (bladder injury); no intraoperative complications were recorded in the LH group. No differences in Accordion grade 2 (or worse) postoperative complications were observed (1 of 40 [2.5%] in the LH group vs 3 of 40 [7.5%] in the VH group; P = 0.61; odds ratio, 3.1; 95% CI, 0.3-31.8), and no postoperative deaths occurred., Conclusions: Our findings suggest the noninferiority of LH to VH. LH improves the postoperative course of older women undergoing surgical operation for benign uterine diseases. If an appropriate indication exists, LH should not be denied based on mere chronological age.

Objective: The aim of this study was to verify possible differences in terms of perioperative outcomes and complications between mini-laparoscopic radical hysterectomy with lymphadenectomy (mLRH) and robotic radical hysterectomy with lymphadenectomy (RRH) in patients with early cervical cancer (ECC)., Material and Methods: In this retrospective study, thirty women with early stage cervical cancer who underwent mini-laparoscopic radical hysterectomy plus lymphadenectomy (mLRH) were compared with a cohort of thirty women who underwent robotic multiport radical hysterectomy (RRH). The study involved patients, between August 2010 and December 2012, from three Italian institutions: National Cancer Institute of Rome, University of Insubria, Varese, and the Catholic University of the Sacred Heart of Rome., Results: No significant differences between groups were observed in terms of age, BMI, previous abdominal surgery or FIGO stage. Operative time, blood loss, need of blood transfusion, risk of intra- and post-operative complications, and lymph nodes yield were similar between mLRH and RRH in patients with ECC. The median length of hospital stay was 2 days in the mLRH group and 3 days in the RRH group (p < 0.05)., Conclusions: The few differences we registered do not seem clinically relevant, thus making the two procedures comparable. The decision on how to gain best access for radical hysterectomy considers the surgeon's skill and experience with the different possible approaches. Further randomized trials are needed to determine whether mini-laparoscopic techniques truly offer any advantages., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Identification of peri-operative variables predicting postoperative morbidity may improve postoperative patients' care. We aimed to identify patients' characteristics and operative factors predictive of early (≤ 30-day) and late (≤ 6-month) morbidity in cervical cancer patients undergoing surgery plus external beam radiotherapy (EBRT)., Methods: We studied 45 propensity-matched patient pairs (90 patients) undergoing laparoscopic radical hysterectomy (LRH) plus EBRT vs. abdominal radical hysterectomy (RAH) plus EBRT. Basic descriptive, multivariable and artificial neuronal network analyses (ANN) were used to design predicting models influencing outcomes., Results: Baseline characteristics of the study populations were similar. Patients undergoing LRH experienced lower blood loss (200 (range, 10-700) vs. 400 (range, 100-2000) ml; P < 0.001), shorter length of hospital stay (4 (range, 1-10) vs. 8 (range, 5-52) days; P < 0.001) and similar operative time (235 (± 67.3) vs. 258 (± 70.2) min; P = 0.14) than patients undergoing RAH. We observed that, at multivariate analysis, open approach correlated with overall (OR: 1.2; 95%CI: 1.03-1.46), early (OR: 1.14; 95%CI:0.99-1.3) and late (OR: 1.13; 95%CI: 1.001-1.28) postoperative complications., Conclusions: Open approach is the main predictor for developing morbidity among cervical cancer patients undergoing radical hysterectomy followed by adjuvant radiotherapy. Laparoscopic surgery enhances peri-operative surgical results and minimizes the occurrence of late complications., (© 2014 Wiley Periodicals, Inc.)

Study Objective: To compare perioperative and long-term outcomes related to laparoscopic and open abdominal surgical management of cervical cancer., Design: Propensity-matched comparison of prospectively collected data (Canadian Task Force classification II-1)., Setting: University teaching hospital., Patients: Sixty-five propensity-matched patient pairs (130 patients) undergoing either laparoscopy or open abdominal surgical procedures to treat cervical cancer., Intervention: Radical hysterectomy plus lymphadenectomy was performed via the laparoscopic (LRH) or open abdominal approach (RAH)., Measurement and Main Results: Baseline characteristics of the study populations were similar. In the LRH group the procedure was converted to open surgery in 2 patients (2%). Compared with the RAH group, patients undergoing LRH experienced less blood loss (200 vs 500 mL; p < .001), a lower transfusion rate (6% vs 22%; p = .02), similar operative time (245 vs 259.5 minutes; p = .26), and shorter length of hospital stay (4 vs 8 days; p < .001). No between-group differences in intraoperative complications were recorded (p = 1.0); however, a trend toward a lower postoperative complication rate (Accordion system grade ≥ 3) was observed for LRH compared with RAH (4 patients [6%]) vs 12 patients [18%]; p = .06). Five-year disease-free survival (p = .6, log-rank test) and overall survival (p = .31, log-rank test) did not differ statistically between women undergoing LRH or RAH., Conclusion: Laparoscopy ensures the same results as open surgery insofar as radicality and long-term survival. Use of the laparoscopic approach is associated with improved short-term results, minimizing the occurrence of severe postoperative complications., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Herein is described a technique for minimally invasive management of peripartum subtotal hysterectomy. A video of peripartum emergency subtotal hysterectomy in a patient with retained placenta and suspicion of accretism is presented. The procedure has been accomplished totally via laparoscopy, with transcervical extraction of the specimen. To our knowledge, this is the first description of a peripartum subtotal hysterectomy performed via laparoscopy., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To compare the use of low pneumoperitoneum pressure (LPP; 8 mm Hg) vs standard pneumoperitoneum pressure (SPP; 12 mm Hg) during mini-laparoscopic hysterectomy (MLH)., Design: Randomized controlled trial (Canadian Task Force classification I)., Setting: Tertiary care center., Patients: Forty-two consecutive women scheduled to undergo MLH to treat benign uterine disease., Interventions: Women were randomly selected to undergo MLH using LPP (n = 20) or SPP (n = 22). MLH was performed via 3-mm ancillary ports., Measurements and Main Results: The primary outcome was to evaluate changes in abdominal and shoulder-tip pain via a 100-mm visual analog scale at 1, 3, and 24 hours postoperatively. All procedures were completed via mini-laparoscopy without the need to increase intra-abdominal pressure or convert to conventional laparoscopy or open surgery. Intraoperatively, 1 episode of severe bradycardia occurred in the LPP group, whereas no intraoperative complications were recorded in the SPP group (p = .47). No postoperative complications were recorded (p > .99). Abdominal pain was similar between groups at each time point. Incidence and intensity of shoulder-tip pain at 1 and 3 hours postoperatively was lower in the LPP group than in the SPP group (p < .05), whereas no between-group differences were observed at 24 hours (p > .05). Rescue analgesic requirement did not differ statistically between the LPP and SPP groups (20% vs 41%, respectively; p = .19; odds ratio, 2.7; 95% confidence interval, 0.69-11.08)., Conclusion: In experienced hands, use of LPP is safe and feasible. During performance of MLH, compared with SPP, LPP is a simple method that offers advantages of less shoulder-tip pain., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to determinate whether the introduction of nerve-sparing (NS) procedure influences surgical and survival outcomes of cervical cancer patients undergoing laparoscopic radical hysterectomy (LRH)., Methods: Data of consecutive patients undergoing minimally invasive radical with or without NS surgery for cervical cancer were enrolled in the study., Results: Sixty-three patients (66%) who had LRH were compared with 33 women (34%) undergoing NS-LRH. Among the NS group, 19 patients (57.6%) had surgery via minilaparoscopy (using 3-mm instruments). Baseline characteristics were similar between groups. Patients undergoing NS-LRH had shorter operative time (210 vs 257 minutes; P = 0.005) and higher number of pelvic lymph nodes yielded (29 [26-38] vs 22 [8-49]; P < 0.001) than patient in the control group. No differences in blood loss, complications, and parametrial width were observed. Patients were catheterized with an indwelling Foley catheter for a median of 3.5 days (2-7 days) and 5.5 days (4-7 days) in NS and non-NS groups, respectively (P = 0.01). Voiding dysfunctions occurred in 1 patient (3%) and 12 patients (19%) who underwent NS-LRH and standard LRH, respectively (P = 0.03). No differences in 3-year disease-free survival (P = 0.72) and overall survival (P = 0.71) were recorded., Conclusions: The beneficial effects (in terms of operative time and number of nodes harvested) of NS-LRH are likely determined by the expertise of the surgeon because NS approach was introduced after having acquired adequate background in conventional LRH. Our data show that in experienced hands NS-LRH is safe and feasible. Moreover, NS technique reduces catheterization time and the rate of postoperative urinary dysfunction.

Study Objective: To present our experience with laparoscopic hysterectomy (LH) for uteri weighing 1 kilogram or more and to provide a systematic review of the available English literature., Design: Retrospective analysis and review of the literature (Canadian Task Force Classification II-2)., Setting: Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy., Patients: All women in whom LH was attempted at the Department of Obstetrics and Gynecology, University of Insubria for uteri weighing ≥1 kg were included in the present study. Demographic characteristics and perioperative details of patients were prospectively recorded in our institutional surgical database. We also performed a systematic review of the English literature to identify studies including at least 1 case of LH for uteri weighing ≥1 kg., Interventions: Hysterectomy for uteri ≥1 kg was performed through a total laparoscopic approach with vaginal morcellation of the uterus in the majority of patients and transvaginal closure of the vaginal vault in all cases., Measurements and Main Results: LH was attempted in a total of 71 women. The median uterine weight was 1120 g (1000-2860 g). Three (4.2%) conversions to open surgery were needed. The median operative time and blood loss were 120 minutes (55-360 minutes) and 200 mL (10-1000 mL), respectively. No intraoperative and 2 (2.8%) postoperative complications occurred. Our review identified 6 studies reporting details of LH for uteri weighing ≥1 kg for a total of 62 patients; conversion to open surgery was necessary in 6 (9.7%) patients, and an additional 13 (21%) received a minilaparotomic incision to extract the uterus. The overall complication rate reported in the literature was 11.4%., Conclusion: LH represents a possibility even in cases of uteri weighing ≥1 kg. In a dedicated setting with high endoscopic experience, conversion and complication rates appear acceptable., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Aim: To present our preliminary experience with nerve-sparing minilaparoscopic radical hysterectomy plus pelvic lymphadenectomy for the surgical treatment of cervical cancer and to compare outcomes with those of the conventional laparoscopic approach., Methods: Data of 87 consecutive women who underwent minimally invasive surgery for early and locally advanced stage cervical cancer were prospectively collected. Ten women who underwent laparoscopic surgery using a nerve-sparing technique performed through 3-mm ancillary ports were compared with the 77 patients who had standard laparoscopic surgery previously with 3 sovrapubic 5-mm trocars., Results: Minilaparoscopic radical hysterectomy was successfully accomplished in every case with no conversion to standard laparoscopy or open surgery. Two (2.6%) conversions to open surgery occurred in the conventional laparoscopy group. Surgical characteristics (operative time, estimated blood loss, and length of stay) and complication rate were similar between the 2 groups. No differences in the amount of parametrial and vaginal tissue removed were observed. The number of lymph nodes retrieved through minilaparoscopy was higher than conventional laparoscopy (30 [range = 26-38] vs 22 [range = 8-49]; P = .002). However, no difference was observed when the analysis was restricted to the last 10 conventional procedures (30 [range = 26-38] vs 29 [range = 24-49]; P = .81)., Conclusions: Our data show that minilaparoscopic radical hysterectomy with pelvic lymphadenectomy is a feasible procedure if performed by skilled surgeons.

Objective: To analyze the preliminary experience of three gynecologic oncology services with minilaparoscopic radical hysterectomy (mLRH) for the treatment of cervical cancer and to compare perioperative outcomes with those of conventional laparoscopic surgery (LRH)., Methods: Prospectively collected data on consecutive cervical cancer patients undergoing radical hysterectomy with a laparoscopic approach were analyzed retrospectively. Perioperative outcomes of women undergoing mLRH were compared to data from control patients who had undergone LRH with 5-mm instruments. Adjustment for potential selection bias in surgical approach was made with propensity score (PS) matching., Results: The study cohort consisted of 257 patients, 35 undergoing mLRH and 222 undergoing LRH. The two groups were comparable in terms of demographic and tumor characteristics. No significant differences were observed between groups in terms of operative time, blood loss, lymph node yield, amount of parametrial or vaginal cuff tissue removed, and percentage of intra- or postoperative complications, both in the entire cohort and in the PS matched group. No conversions were needed from mLRH to standard laparoscopy or from minilaparoscopy to open surgery. Conversion from standard laparoscopy to open surgery was necessary in 2 patients. A shorter hospital stay was observed among women who had mLRH than in those undergoing LRH [2 (1-10) vs 4 (1-14) days, p = 0.005]. This difference remained significant after PS matching., Conclusion: Our preliminary study suggests that in experienced hands minilaparoscopy is a feasible and safe technique for radical hysterectomy and yields results that are equivalent to those of LRH., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Study Objective: To investigate the effect of uterine weight on the mode of hysterectomy and on perioperative outcomes and to explore how the increasing experience in endoscopic techniques influenced our choice of surgical approach to hysterectomy to treat benign conditions., Design: Retrospective analysis (Canadian Task Force classification II-2)., Setting: University-based department of obstetrics and gynecology., Patients: A series of 1518 consecutive women with benign uterine conditions other than pelvic organ prolapse who underwent hysterectomy at our department between January 2000 and December 2011., Interventions: Gradual implementation of the laparoscopic approach over years, with the goal of attempting endoscopic hysterectomy whenever possible and irrespective of uterine weight. Comparisons were made on the basis of various approaches to hysterectomy including vaginal hysterectomy (VH), abdominal hysterectomy (AH), and total laparoscopic hysterectomy (TLH) and on uterine weight., Measurements and Main Results: Hysterectomies performed included 568 VH (37.4%), 234 AH (15.4%), and 716 TLH (47.2%). Postoperative complications were lower in the TLH group vs the AH group; no significant difference was observed between the VH vs TLH groups or the AH vs VH groups. A marked reduction in the need for open surgery was noted between 2000 and 2011 (p for trend <.001). Restricting the analysis to TLH, an increase in operative time and blood loss was observed, parallel to increasing uterine weight. Hospital stay and rate of intraoperative and postoperative complications were independent of uterine weight. In 45 women with uterus weight ≥1000 g, the initial approach was via laparoscopy, with a success rate of 95.6% (n = 43). A marked tendency toward reduction in the use of open surgery was observed through the years when uterine weight was ≥1 kg (p for trend <.001)., Conclusion: Systematic implementation of laparoscopic hysterectomy enables a marked reduction in the need for AH. In experienced hands, even very large uteri (≥1 kg) can be safely removed via laparoscopy., (Copyright © 2013 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Despite the lack of conclusive evidence supporting this treatment modality, neoadjuvant chemotherapy (NACT) prior to radical surgery is a commonly accepted strategy to manage locally advanced cervical cancer. Radical hysterectomy in chemotherapy-treated patients can be technically challenging due to large volume of residual disease, desmoplastic reaction, and loss of normal tissue planes as a result of the cytotoxic treatment. We sought to assess whether surgical outcomes of laparoscopic radical hysterectomy (LRH) and its open counterpart are equivalent in the setting of NACT., Methods: Prospectively maintained databases of five gynecologic oncology services were searched for stage IB2-IIB cervical cancer patients undergoing surgery after NACT. LRH and open radical hysterectomy (RAH) patients were compared with respect to perioperative outcomes and mid-term survival. Adjustment for potential selection bias in surgical approach was made with propensity score (PS) matching., Results: LRH cases (n = 68) were associated with lower-stage, lower-grade tumors compared with RAH group (n = 273). When patients were grouped by stage at presentation (IB2-IIA and IIB), complication rates and perioperative outcomes were equivalent between LRH and RAH groups. LRH offered less blood loss, lower transfusion rate, and shorter hospitalization. These differences remained significant after PS matching. In the PS-matched cohort, Cox proportional hazards model including tumor stage, grade, histotype, nodal status, institution, and time period of surgery showed that laparoscopic approach was not associated with impaired survival., Conclusion: Laparoscopic approach seems a valuable alternative to open surgery for patients with locally advanced cervical carcinoma who have received NACT.

Objective: To investigate the risk of vaginal cuff dehiscence after different routes of hysterectomy and methods of cuff closure., Methods: A multi-institutional analysis of 12,398 patients who underwent hysterectomy for both benign and malignant disease between 1994 and 2008 was performed. We analyzed how different routes of hysterectomy and approaches to cuff suture may influence the risk of development of vaginal dehiscence., Results: Women who had total laparoscopic (n=3,573), abdominal (n=4,291), and vaginal (n=4,534) hysterectomies experienced 23 (0.64%), 9 (0.2%), and 6 (0.13%) cases of vaginal cuff dehiscence, respectively. Total laparoscopic hysterectomy was associated with a higher incidence of cuff separations, compared with abdominal hysterectomy (0.64% compared with 0.21%, P=.003) and vaginal hysterectomy (0.64% compared with 0.13%, P<.001). Within the endoscopic group, patients who underwent vaginal closure with laparoscopic knots had a higher rate of cuff dehiscence than patients who had suture with transvaginal knots (20 of 2,332 [0.86%] compared with 3 of 1,241 [0.24%], P=.028). When vaginal suture was performed transvaginally, no statistical difference in vaginal cuff dehiscence rate was observed compared with both abdominal hysterectomy (0.24% compared with 0.21%, P=.83) and vaginal hysterectomy (0.24% compared with 0.13%, P=.38). Use of monopolar energy at the time of colpotomy and reducing the power of monopolar energy from 60 watts to 50 watts when colpotomy was performed at the end of total laparoscopic hysterectomy did not alter the rate of cuff separations., Conclusion: Transvaginal suturing appears to reduce the risk of vaginal dehiscence after total laparoscopic hysterectomy.

Objective: To determine the incidence of vaginal cuff dehiscence after minimally invasive hysterectomy, we reported our series of total laparoscopic hysterectomies with transvaginal colporraphy., Study Design: We then conducted a systematic search of PubMed to retrieve published series of laparoscopic and robotic hysterectomies, in which different techniques for vaginal cuff closure were used., Results: In our study group, vaginal cuff dehiscence occurred in 2 of 665 (0.3%) patients. Our literature search identified 57 articles, for a total of 13,030 endoscopic hysterectomies. Ninety-one postoperative vaginal separations were reported (0.66%). The pooled incidence of vaginal dehiscence was lower for transvaginal cuff closure (0.18%) than for both laparoscopic (0.64%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65) and robotic (1.64%; OR, 0.11; 95% CI, 0.04-0.26) colporraphy. Laparoscopic cuff closure was associated with a lower risk of dehiscence than robotic closure (OR, 0.38; 95% CI, 0.28-0.6)., Conclusion: Current evidence indicates that transvaginal colporraphy after total laparoscopic hysterectomy is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Study Objective: To compare operative outcomes and postoperative pain of laparoscopic hysterectomy (LH) versus minilaparoscopic hysterectomy (MLH)., Design: Randomized controlled trial (Canadian Task Force Classification I)., Setting: Tertiary care center., Patients: Seventy-six women scheduled to undergo a hysterectomy for a supposed benign gynecologic condition., Interventions: Participants were randomly assigned to LH (n = 38) or MLH (n = 38). MLH was performed with use of 3-mm ports. Both patients and assessors of the postoperative outcomes were blinded to the size of port used, and patients' wounds were concealed by standard-size nontransparent dressings., Measurements: Primary outcome was postoperative pain (both rest and incident on coughing and abdominal pain, as well as shoulder pain) by use of a 100-mm visual analogue scale., Main Results: The two groups were similar in terms of operative outcomes. No intraoperative conversion from MLH to both LH and open surgery occurred. No significant difference in pain scores at 1, 3, 8, and 24 hours after surgery between groups was found. Rescue analgesic requirement was similar in the MLH and LH groups (21.1% vs 13.2%, p =.54)., Conclusions: Ports can safely be reduced in size without a negative impact on the surgeon's ability to perform LH. MLH appears to have no advantage over LH in terms of postoperative pain., (Copyright © 2011 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: Surgical treatment for cervical cancer is associated with a high rate of late postoperative complications, and in particular with sexual dysfunction., Aim: To evaluate sexual function in women who underwent radical hysterectomy (RH), in comparison with a control group of healthy women, using a validated questionnaire (Female Sexual Function Index [FSFI]). Then we tried to evaluate the possible differences between laparoscopic RH and abdominal RH in terms of their impact on sexuality., Methods: Consecutive sexually active women, who underwent RH for the treatment of early-stage cervical cancer between 2003 and 2007, were enrolled in this study (cases) and divided into two groups, according to the surgical approach. All women were administered the FSFI. The results of this questionnaire were compared between patients who underwent laparoscopic RH (LPS group) vs. women who underwent laparotomic RH (LPT group). The cases of RH were also compared with a control group of healthy women, who were referred to our outpatient clinic for a routine gynecologic evaluation., Main Outcome Measures: FSFI questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, pain)., Results: A total of 38 patients were included. We also enrolled 35 women as healthy controls. FSFI score was significantly higher in the healthy controls vs. the cases of RH. In the LPS group, the total score and all the domains of the FSFI were lower in comparison with the healthy controls, whereas three of the six domains (arousal, lubrication, orgasm) and the total score of FSFI were lower in the LPT group if compared with the controls. There were no significant differences between LPS and LPT group., Conclusions: RH worsens sexual function, regardless of the type of surgical approach. In our experience, laparoscopy did not show any benefit on women's sexuality over the abdominal surgery for cervical cancer.