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Background: Total laparoscopic hysterectomy (TLH) is becoming an increasingly popular treatment in endometrial cancer. Intra-abdominal or vaginal uterus morcellation are well described and routinely practiced techniques in removing a benign bulky uterus but contraindicated in endometrial cancer. In malignancy, the uterus needs to be removed intact to avoid intraperitoneal spillage of the endometrial cancer cells, and a uterine size of 12 gestational weeks (g.w.) or larger has been considered a contraindication for the laparoscopic approach. The aim of our study was to evaluate the feasibility and safety of a sealed vaginal morcellation technique in a bag for endometrial cancer laparoscopic treatment., Methods: We prospectively scheduled 12 patients affected by endometrial cancer with uterus bigger than 12 g.w. for endometrial cancer laparoscopic treatment. After performing TLH, a sterile plastic wrapping bag was inserted by a 12 mm camera port by rolling it onto the blunt probe. The uterus was covered from the fundus to the cervix, placing the free edges of the bag down into the manipulator cup with two blunt graspers. The specimen completely covered by the bag was then pushed down under direct laparoscopic vision through colpotomy and pulled out from the vagina. The uterus was morcellated by the vaginal route., Results: All patients underwent laparoscopic treatment with vaginal uterine morcellation. The mean uterus weight was 290.8 ± 79.7 g with a mean morcellation operative time of 12.1 min. All vaginal morcellations were completed successfully. All patients were without evidence of local or distant recurrence at the median follow-up time of 18 months., Conclusions: This technique allows the surgeon to morcellate a bulky uterus in cases of endometrial cancer and reduces the chance of neoplastic cell spillage during debulking at TLH. Vaginal morcellation following oncologic rules permits a rapid uterine extraction and may avoid a number of unnecessary laparotomies.

Objective: Vaginally assisted laparoscopic sacrocolpopexy (VALS), which is a combined surgical approach where a vaginal hysterectomy is initially performed, followed by transvaginal placement of synthetic mesh and laparoscopic suspension, can be an alternative to overcome the dissection, suturing limitations of laparoscopic sacrocolpopexy. The aim of this study was to compare the operative times and middle-term anatomic outcomes of women with uterovaginal prolapse undergoing VALS with those of women undergoing abdominal sacrocolpopexy., Methods: This is a prospective cohort study that evaluates operation times, anesthesia times, estimated blood loss, middle-term outcomes, perioperative and postoperative complications. We compared the results of 47 women who had the VALS to that of 32 abdominal sacrocolpopexy (AS)., Results: The mean follow up was 22.4 months for AS group and 20.5 months for VALS group. The VALS group (median 1 day) had shorter hospitalization duration than the AS group (median 3 days). The mean operation time was significantly shorter in the VALS group (125.9 minutes) than the AS group (151.9 minutes) (P = .03). There was no significant difference in perioperative and postoperative complication rates. Objective failure rate (8.5% in VALS, 15.6% in AS), subjective failure rates (6.4% in VALS, 9.4% in AS), recurrence (2.1% in VALS, 9.4% in AS) and mesh exposition rates (2.1% in VALS, 9.4% in AS) were similar in both procedures., Conclusions: VALS with shorter operative time and hospitalization than conventional AS is a promising modification minimally invasive technique for sacrocolpopexy especially for those inexperienced in laparoscopic sacrocolpopexy., (© 2020 John Wiley & Sons Australia, Ltd.)

Uterine fibromas are the most common benign uterine tumors. Although the majority of leiomyomas remain asymptomatic, they can cause serious clinical problems, including abnormal uterine bleeding, pelvic pain, and infertility, which require effective gynecological intervention. Depending on the symptoms as well as patients' preferences, various treatment options are available, such as medical therapy, non-invasive procedures, and surgical methods. Regardless of the extent of the surgery, the preferred option is the laparoscopic approach. To reduce the risk of spreading occult malignancy and myometrial cells associated with fragmentation of the specimen before its removal from the peritoneal cavity, special systems for laparoscopic contained morcellation have been developed. The aim of this review is to present the state-of-the-art contained morcellation. Different types of available retrieval bags are demonstrated. The advantages and difficulties associated with contained morcellation are described. The impact of retrieval bag usage on the course of surgery, as well as the effects of the learning curve, are discussed. The role of contained morcellation in the overall strategy to optimize patient safety is highlighted. [ABSTRACT FROM AUTHOR]

Background: Electromechanical power morcellation is an important tool of modern laparoscopy. Recent reports on the spread of previously undetected malignancy by power morcellation indicate the need for additional protective devices to reduce this risk. We conducted a study to obtain the first data concerning the safety of an endobag with three closable ports during morcellation and subsequent bag extraction under in vitro conditions, mimicking the settings in our operating theater. The second purpose of the study was to establish a minimal width of the skin incision necessary to safely extract the sealed bag after morcellation.Methods: The morcellation test was carried out on 11 stained porcine muscle tissue samples with one additional sample as a control. The insufflation pressure was set at 12 mmHg. After filling the endobag with blue dye solution, an additional extraction test was conducted by pulling the closed bag through a template with apertures of various diameters. For each opening, a series of ten bag extractions was carried out.Results: No loss of solid material or fluid was recorded during the morcellation test. The extraction test showed a loss of fluid for template openings smaller than 18 mm. The force necessary to extract the bag was inversely related to the width of the aperture.Conclusions: The data suggest that under the evaluated conditions, the use of a closable morcellation bag can considerably improve the patient's safety during morcellation. Further studies are necessary to evaluate the influence of the bag on operating time, intervention costs and complications. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic techniques have successfully reduced the invasiveness of hysterectomy, when compared to open procedures. Power morcellation, as a part of the minimal invasive concept, carries the risk of disseminating cells from the tissue specimen. The present observational study reports on first experiences using a new system (More-Cell-Safe, A.M.I., Austria) for contained in-bag morcellation during laparoscopic hysterectomy.Materials and Methods: The dual opening system allows two-port access without bag puncture. The optic is protected against spread cell contamination with a disposable sleeve. Application data were prospectively recorded on the first n = 7 consecutive patients and compared to n = 7 preceding patients undergoing uncontained morcellation.Results: Bag system use was surgically successful in 6 of 7 cases (85.7 %). Morcellated specimen weight ranged from 205 to 638 g (mean 413.33 ± 176.85; median 413). In one patient, the uterine specimen (1050 g) proved too large to be placed into the bag. Average time associated to the bag use was 16.2 ± 7.65 min, ranging from 8.5 to 26.5 min (median 14 min). Removed bags contained bloody fluid with residual tissue fragments weighing overall between 21 and 85 g. Spread spindle cells were detected in two cases after uncontained morcellation, but not after in-bag morcellation.Conclusion: The experiences from our small pilot series prove technical feasibility in the clinical setting. [ABSTRACT FROM AUTHOR]

Introduction: Minimal invasive approaches have proven beneficial for patients undergoing myomectomy and hysterectomy, but necessary tissue morcellation carries the risk of cell dissemination in rare cases of inadvertent malignancy. Performing the morcellation process within a contained bag system may prevent spilling and therefore enhance safety of the laparoscopic procedures.Material and Methods: The present study describes the development and experimental evaluation of a new bag system in vitro and in vivo in a pig model of laparoscopic supracervical hysterectomies.Results: The main results on n = 8 procedures with in-bag morcellation compared to n = 8 controls without bag indicate reproducible feasibility and protective effect of the new bag, which is the first published to our knowledge that does not require puncturing in a standard multiport laparoscopy setting. Overall surgery time was significantly prolonged in the bag group by 12.86 min (P = 0.0052; 95 % confidence interval 4.64-21.07), but peritoneal washings were negative for muscle cells in all cases with bag use, compared to positive cytology in 5/8 cases without bag (P = 0.0256).Conclusion: Clinical trials will now be necessary to investigate the reproducibility of these encouraging data in human application. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aim was to review the safety and efficacy of pelvic organ prolapse surgery for vaginal apical prolapse. Methods: Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials (RCT) or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and or 3 studies, or 'majority evidence' from RCTs. Grade C recommendation usually depends on level 4 studies or 'majority evidence‟ from level 2/3 studies or Delphi processed expert opinion. Grade D 'no recommendation possible' would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Results: Abdominal sacral colpopexy (ASC) has a higher success rate than sacrospinous colpopexy with less SUI and postoperative dyspareunia for vault prolapse. ASC had greater morbidity including operating time, inpatient stay, slower return to activities of daily living and higher cost (grade A). ASC has the lowest inpatient costs compared with laparoscopic sacral colpopexy (LSC) and robotic sacral colpopexy (RSC). LSC has lower inpatient costs than RSC (grade B).In single RCTs the RSC had longer operating time than both ASC and LSC (grade B). In small trials objective outcomes appear similar although postoperative pain was greater in RSC. LSC is as effective as ASC with reduced blood loss and admission time (grade C). The data relating to operating time are conflicting. ASC performed with polypropylene mesh has superior outcomes to fascia lata (level I), porcine dermis and small intestine submucosa (level 3; grade B). In a single RCT, LSC had a superior objective and subjective success rate and lower reoperation rate compared with polypropylene transvaginal mesh for vault prolapse (grade B).Level 3 evidence suggests that vaginal uterosacral ligament suspension, McCall culdoplasty, iliococcygeus fixation and colpocleisis are relatively safe and effective interventions (grade C). Conclusion: Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse. Polypropylene mesh is the preferred graft at ASC. Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy. [ABSTRACT FROM AUTHOR]