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Objectives The Canadian Institute of Health Information (CIHI) Discharge Abstract Database (DAD) is the main source of routinely-collected data for gynecologic surgery in Canada and are increasingly used for research. As these data were originally collected for healthcare administrative purposes, like billing or surveillance, they are prone to error and should be validated prior to their use for clinical research. The objective of this study was to validate hysterectomy codes from the CIHI-DAD at a single institution. Methods We obtained a consecutive sample of all gynecologic procedures performed from April 2016 to March 2017 using the CIHI-DAD at The Ottawa Hospital. Patient data, including diagnosis, procedure type, and surgical approach, were reabstracted from charts. Reabstracted chart data were then compared to CIHI-DAD Canadian Classification of Health Interventions (CCI) codes using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and kappa coefficient with associated 95% confidence intervals. Results Of 1079 gynecologic procedures, 649 hysterectomies were performed, including 23.3% vaginally, 17.1% laparoscopically, and 14.9% abdominally. The median patient age was 46years (interquartile range:41-54). The sensitivity, specificity, PPV, NPV, and kappa, with associated 95% confidence intervals, for all hysterectomies was94.8%(92.8-96.4%), 88.4%(85.0-91.3%), 92.5%(90.2-94.4%), 91.8%(88.7-94.3%) and 0.84(0.80-0.87%), respectively. For vaginal hysterectomy, sensitivity=88.8%(84.3-92.5%), specificity=99.2%(98.3-99.7%), PPV=97.0%(93.8-98.9%), NPV=96.7%(95.3-97.8%), and kappa=0.91(0.87-0.94). For laparoscopic hysterectomy, sensitivity=91.3%(86.3-95.0%), specificity=92.8%(91.0-94.4%), PPV=72.4%(66.2-78.1%), NPV=98.1%(97.0-98.9%), and kappa=0.79(0.71-0.81). For abdominal hysterectomy, sensitivity= 96.9%(93.9-99.0%), specificity=94.9%(93.2-96.2%), PPV=76.8%(70.4-82.5%), NPV=99.4%(98.7-99.8%), and kappa=0.83 (0.78-0.87). Conclusions Our study suggests a high level of validity for hysterectomy CCI codes in the CIHI-DAD for clinical research purposes.

The aim of this study is to evaluate the efficacy, safety, anatomical and functional outcomes of patients undergoing laparoscopic sacrocolpopexy (LSC) using light-weight Y mesh for post hysterectomy vaginal prolapse.A retrospective observational study of women who underwent LSC for post hysterectomy vaginal vault prolapse between January 2010 and January 2019. Y shaped mesh was used for the LSC after dissection of the rectum and the bladder. Pre-operative evaluation included symptoms' assessment using the Prolpase Quality of Life Questionnaire (P-QOL) and objective assessment using the POP-Q scores. Post operatively, patient symptoms, anatomical outcomes, mesh complications and patient global impression of improvement scores were evaluated. Patients were followed up at 12 months and yearly thereafter.247 consecutive patients were included in this study. Patients' age ranged from 35 to 86 years old with an average BMI of 28.8. The most common presenting symptoms were vaginal bulge (95%), vaginal heaviness (73%) and urinary urgency (46%). The time interval between hysterectomy and LSC was 10.5 years (5 months - 42 years). Complications reported were bladder injury (1.6%), small bowel injury (0.8%), major haemorrhage (0.4%), vaginal mesh extrusion (1.2 %). 85.8% of women reported cure of prolapse symptoms. 14.2% of patients developed further/unresolved prolapse symptoms and 6.5% went on to have further surgery for prolapse. 10% of women developed new onset dyspareunia. Anatomically, postoperative point C (apex) was at -7.6 cm (range -9 - +3 cm) CONCLUSION: LSC using Y mesh for post hysterectomy vaginal prolapse is safe. LSC is effective in 85% of women who develop vaginal prolapse post hysterectomy. Further surgery for bothersome prolapse symptoms were needed in 6.5% with a 1.2% mesh extrusion rate and 10% new onset dyspareunia. This will help in counselling women undergoing this surgery.

INTRODUCTION AND HYPOTHESIS: To compare body image and sexual activity and function changes up to 3 years after sacrospinous ligament fixation with t graft hysteropexy or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy). METHODS: This was a planned secondary analysis of a multi-center randomized trial of women undergoing prolapse repair with mesh hysteropexy versus hysterectomy. Women were masked to intervention. The modified Body Image Scale (BIS), sexual activity status and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) scores were reported at baseline and 1.5, 6, 12, 18, 24 and 36 months after surgery. We compared mean BIS and PISQ-IR scores, the proportion of women whose BIS scores met a distribution-based estimate of the minimally important difference (MID), and sexual activity status. Comparisons were analyzed with linear and logistic repeated measures models adjusted for site, intervention, visit, and intervention by visit interaction. RESULTS: Eighty-eight women underwent mesh hysteropexy; 87 underwent hysterectomy. Women were similar in baseline characteristics: Mean age 65.9 +/− 7.3 years and most had stage III or IV prolapse (81%). Baseline mean BIS scores were not significantly different, ,improved in both groups by 1.5 months and were sustained through 36 months with no differences between groups (all p>0.05). The estimated BIS MID was 3; and by 36 months, more women in the mesh hysteropexy group achieved the MID than in the hysterectomy group (62% vs 44%, p=0.04). The makeup of the sexually active cohort changed throughout the study, making function comparisons difficult. CONCLUSIONS: Body image improves following prolapse surgery whether or not hysterectomy is performed or transvaginal mesh is used at the time of repair; sexual activity status changes over time following prolapse surgery.

Objectives There is conflicting research on the effect of therapeutic suggestion in the perioperative period. This study systematically compared subjective and objective measures of postoperative pain, nausea and vomiting, urinary and bowel function, and global perception of symptomatic improvement between participants receiving perioperative therapeutic suggestion versus routine perioperative care during minimally invasive pelvic reconstructive surgery. Methods This was a single-blinded, randomized controlled trial of participants undergoing vaginal hysterectomy with minimally invasive sacrocolpopexy and concomitant prolapse repairs. The intervention group received perioperative therapeutic suggestion, whereas the control group did not. Primary outcomes included postoperative pain scores and analgesic use. Secondary outcomes included a postoperative nausea and vomiting scale, the Pelvic Floor Distress Inventory Questionnaire-Short Form 20, the Patient Global Impression of Improvement scale, and time to return of bowel and bladder function. Results Sixteen participants were randomized to each group. Final analysis included 15 intervention and 14 control participants. Overall measures of postoperative pain and analgesic use were low across all participants without a significant difference between intervention and control groups (opioid: 52.5; interquartile range [IQR], 25.5-58.9 vs 66 IQR, 7.3-125.8; morphine milligram equivalents; P = 0.64; acetaminophen: 2225 mg; IQR, 500-2600 mg vs 2800 mg; IQR, 650-4775 mg; P = 0.38). There were no statistically significant differences in secondary outcomes of urinary symptoms, bowel function, and subjective improvement of prolapse symptoms. Conclusions No differences in postoperative pain, analgesic use, return of bowel and bladder function, or pelvic organ prolapse symptoms were noted in participants receiving perioperative therapeutic suggestion versus routine perioperative care.

Objective: To compare urodynamic changes before and after hysterectomy (laparoscopic vs. vaginal approach) for benign gynecological diseases.Patients and methods: A total of 90 women with a mean age of 56.36-years were enrolled in this study between August 2019 and April 2021. They were divided into two equal groups(45 patients each). Group, I had a vaginal hysterectomy, and Group II had a laparoscopic hysterectomy. All patients were assessed clinically using ICIQ-FLUTS questionnaire and a uro-dynamic study before and six months after surgery. Results: Both vaginal and laparoscopic hysterectomy did not significantly change the maximum flow rate, voiding time, and average flow rate. The increase in residual urine volume in group I was not significant (p = 0.129), as was in Group II(p = 0.217). All the modifications, however, were within permis-sible limits. According to the cystometry result, volume at initial sensation rose in both groups after surgery, with no statistically significant difference (p = 0.364). After both forms of hysterecto-my, maximum bladder capacity did not vary considerably. Preoperatively, all study participants exhibited no overactivity of the detrusor muscle; nevertheless, following surgery, overac-tivity was noted in 9 patients after vaginal hysterectomy com-pared to three patients after laparoscopic hysterectomy, and all the alterations were within a clinically acceptable range. In addition, the ICIQ-FLUTS score was not significantly different between the study groups. Conclusions: According to the urodynamic study, hysterectomy for benign uterine conditions, whether vaginal or laparoscopic did not adversely affect urinary bladder function.

Study Objective The Hominis surgical system is a novel robot-assisted system, designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We presented our experience of the first 30 RvNOTES hysterectomies assessing the feasibility and safety of this technology. Design A two-center prospective study. Setting Academic tertiary referral centers. The ethics committees approved the study in both centers. Patients Thirty women with benign indication for hysterectomy. Intervention RvNOTES hysterectomy performed by the Hominis surgical system. Measurements and Main Results The primary outcome of the study was the rate of conversion to open or conventional laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment. A total of 15 women were enrolled at each site. The median age was 59 years (range: 37–79) and the median body mass index was 25.4 kg/m2 (range: 17.6–40.0). Twenty-four women (80%) had comorbidities. All the procedures were completed successfully without conversion to open abdominal, traditional vaginal, or conventional laparoscopic surgery. No intraoperative complications were observed. Median blood loss and procedure duration were 50 mL (range: 20–400) and 57 minutes (range: 24–88), respectively. Postoperative pain was minimal, with a median visual analog scale of 3 (range: 1–5) for the first 24 hours following surgery. The median hospital stay was 3 days (range: 2–8). According to the treating physicians’ evaluations, the vaginal cuff was fully healed in all patients at the 6-week postoperative follow-up visit. Conclusions This is the first publication of robot-assisted vaginal hysterectomy using the Hominis surgical system. The positive results of this study show this new technology to be a safe and effective tool for vaginal natural orifice transluminal endoscopic surgery, enabling surgeons to operate vaginally with the known advantages of robotic modality.

Purpose Despite the establishment of radical surgery for therapy of cervical cancer, data on quality of life and patient-reported outcomes are scarce. The aim of this retrospective cohort study was to evaluate bladder, bowel and sexual function in women who underwent minimally invasive surgery for early-stage cervical cancer. Methods From 2007–2013, 261 women underwent laparoscopically assisted radical vaginal hysterectomy (LARVH = 45), vaginally assisted laparoscopic or robotic radical hysterectomy (VALRRH = 61) or laparoscopic total mesometrial resection (TMMR = 25) and 131 of them completed the validated German version of the Australian Pelvic Floor Questionnaire (PFQ). Results were compared with controls recruited from gynecological clinics (n = 24) and with urogynecological patients (n = 63). Results Groups were similar regarding age, BMI and parity. The TMMR group had significantly shorter median follow-up (16 months versus 70 and 36 months). Postoperatively, deterioration of bladder function was reported by 70%, 57% and 44% in the LARVH, VARRVH and TMMR groups, respectively (p = 0.734). Bowel function was significantly worse after TMMR with a higher deterioration rate in 72 versus 43% (LARVH) and 47% (VARRVH) with a correspondingly higher bowel dysfunction score of 2.9 versus 1.5 and 1.8, respectively and 1.8 in urogynaecological patients. Sexual dysfunction was common in all surgical groups. 38% considered their vagina too short which was significantly associated with deep dyspareunia. Compared with controls, surgical groups had significantly increased PFQ scores. Conclusion Pelvic floor dysfunction commonly deteriorates and negatively impacts on quality of life after minimally invasive radical hysterectomy, especially bowel function after TMMR. Pelvic floor symptoms should routinely be addressed pre- and postoperatively.

STUDY OBJECTIVE The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. DESIGN Retrospective propensity-score matched cohort study. SETTING American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. INTERVENTIONS We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. MEASUREMENTS AND MAIN RESULTS The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p

OBJECTIVES: On April 6, 2015, the largest private health insurer in the United States implemented a policy requiring prior authorization for all hysterectomies except those done as outpatient vaginal. The purpose of this policy was to increase utilization of vaginal hysterectomy; however, it is unknown whether this policy had its intended effect. We sought to analyze trends in hysterectomy routes before and after implementation of the prior authorization policy to see if utilization of vaginal hysterectomy increased. METHODS: This was a retrospective study using the Optum® Clinformatics Data Mart national claims database of women enrolled in a single national private health insurer who underwent hysterectomy for any indication between January 1, 2010 and June 30, 2016. Per-quarter utilization of hysterectomy routes (abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal) were compared between the pre- and post-policy time periods using interrupted time series analyses. RESULTS: Data for 305,139 hysterectomies were available—248,821 in the pre-policy period and 56,318 in the post-period. Outpatient vaginal hysterectomy had the greatest increase in utilization of all routes and types; the average utilization per quarter in the pre-policy period was −0.61% and this increased to 0.21% in the post-policy period (p

OBJECTIVE The aim of this study was to describe our experience with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) uterosacral ligament suspension (USLS) and to evaluate the learning curve of mastering the skills to operate this procedure. METHODS This is a prospective study of the first 35 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) (n = 26) and Imelda Hospital (Belgium) (n = 9). The primary outcome was surgical time. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first 24 hours postoperative pain, and the need for analgesia, intraoperative, and postoperative adverse events. RESULTS The median age was 55 years (range, 40-81). The median operative time was 113 minutes (range, 89-233). For the procedures performed at Rambam, total operative time decreased from the first 13 to the following 13: from 149 minutes (range, 89-233 minutes) to 103 (89-170) (

Purpose The aim of this study was to compare survival outcomes of total abdominal radical hysterectomy (TARH) versus laparoscopy-assisted radical vaginal hysterectomy (LARVH) in stage IA2-IB2 cervical cancer. Methods 812 patients who underwent RH between 2008 and 2017 were evaluated in 3 institutions. Progression-free survival (PFS) and overall survival (OS) were analyzed with Kaplan-Meier method and compared by log-rank test. The clinical noninferiority of the LARVH to TARH was assessed with a margin of −7.2%. Noninferiority was demonstrated if the low limit of 95% confidence interval (CI) exceeded its predefined margin. Results 258 patients were treated with TARH and 252 patients with LARVH. TARH and LARVH group had similar 5-year PFS (84.4% vs 86.6%, p = 0.467) and OS rates (85.8% vs 88.0%, p = 0.919). Noninferiority of LARVH to TARH were confirmed with 5-year PFS and OS difference rates of 2.2% (95% CI -2.9–7.3, p = 0.001) and 2.2% (95% CI -2.7–7.1, p = 0.001), respectively. In subgroup of patients with tumors size >2 cm, 5-year PFS (77.6% vs 79.0%, p = 0.682) and OS rates (79.2% vs 81.5%, p = 0.784) did not differ statistically between the two groups. Noninferiority of LARVH to TARH were also confirmed with 5-year PFS and OS difference rates of 1.4% (95% CI -7.0–9.8, p = 0.046) and 2.3% (95% CI -5.8–10.4, p = 0.027), respectively. Conclusion LARVH showed significant noninferiority for PFS and OS versus TARH in early cervical cancer, suggesting the potential oncologic safety of LARVH.

Objective To compare surgical outcomes between total laparoscopic hysterectomy and total vaginal hysterectomy with uterine weight greater than 250 g. Methods We conducted a retrospective cohort study using data from American College of Surgeons' National Quality Improvement Project Hysterectomy Specific Database. Women with uterine weight greater than 250 g undergoing hysterectomy for benign indications by total laparoscopic hysterectomy or total vaginal hysterectomy were matched by propensity scores, which were calculated using preoperative characteristics and uterine weight. Total vaginal hysterectomy was matched to total laparoscopic hysterectomy at a ratio of 1:2. Pairwise analysis was performed using Wilcoxon rank-sum and Fisher exact tests as appropriate. Multivariable logistic regression was performed to identify the independent effect of total vaginal hysterectomy on surgical outcomes. Results There were 1,870 total vaginal hysterectomies that were matched to 3,740 total laparoscopic hysterectomies. No differences in preoperative demographics and comorbidities were seen for the patients. Uterine weight was similar for both groups: 376 g (interquartile range 293-501) for total vaginal hysterectomy and 384 g (interquartile range 302-515) for total laparoscopic hysterectomy (odds ratio [OR] 0.98, 95% CI 0.92-1.09). The rate of composite major complications was similar between total vaginal hysterectomy and total laparoscopic hysterectomy (4.3% vs 5.3%, OR 0.80, 95% CI 0.61-1.05). Intraoperative cystotomies were higher with total vaginal hysterectomy (0.8% vs 0.3%, OR 2.74, 95% CI 1.17-6.61), and ureteral injuries were more common with total laparoscopic hysterectomy (1.2% vs 0.2%, OR 0.12, 95% CI 0.02-0.38). Total vaginal hysterectomy operating time was significantly shorter compared with total laparoscopic hysterectomy (77 minutes, interquartile range 56-111 vs 122 minutes, interquartile range 91-164; OR 0.69, 95% CI 0.42-0.89). After adjusting for confounders, total vaginal hysterectomy was not found to be independently associated with major morbidity (adjusted odds ratio [aOR] 0.95, 95% CI 0.18-5.11) and was associated with a lower probability of operating times exceeding 2.5 hours (aOR 0.31, 95% CI 0.27-0.43). Conclusion In patients matched by uterine size and preoperative characteristics, total vaginal hysterectomy is not associated with an increased composite risk of major surgical morbidity or other adverse surgical outcomes.

To compare the incidence of perioperative complications of total vaginal hysterectomy (TVH) in women with and without a prior cesarean section (CS).Retrospective cohort.Tertiary care academic institution.A total of 742 women who underwent TVH over a 5-year period.TVH.Prior CS did not increase the overall rate of Clavien-Dindo grades 2 to 3 complications (p =.20). The incidence of cystotomy (2.2% CS vs 1.1% no CS, p =.29), ureteral injury (1.1% vs 0.2%, p =.23), proctotomy (1.1% vs 0.2%, p =.23), postoperative bleeding (1.1% vs 0.6%, p =.47), or reoperation (0.0% vs 0.3%, p = 1.00) was not increased from having a prior CS. Prior CS increased blood transfusion (5.6% vs 0.6%, p.05) but did not increase conversion to laparotomy (2.2% vs 0.6%, p =.15), length of hospitalization (11.2% vs 14.1% discharge on the same day, 66.3% vs 63.6% discharge on postoperative day 1, and 22.5% vs 22.4% discharge on or after postoperative day 2, p =.76), or 30-day readmission rates (1.1% vs 3.5%, p =.34).In patients who underwent TVH, a prior CS increased postoperative blood transfusion but did not increase the risk for overall perioperative complications.

INTRODUCTION Natural orifice transluminal endoscopic surgery has been used for gynecologic operations in recent years. The aim of the study is to describe our initial experience using vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) for apical pelvic organ prolapse repair. METHODS After patients underwent vaginal hysterectomy, vNOTES sacrocolpopexy (n = 4) or vNOTES high uterosacral ligament suspension (n = 7) were performed to treat symptomatic apical pelvic organ prolapse. Sociodemographic and clinical characteristics, Pelvic Organ Prolapse Quantification results, and recorded surgical data (eg, duration of surgery, intraoperative complications, additional prolapse and incontinence surgeries) were obtained from patient files and the hospital's database. Information from postoperative follow-up visits, including complications and anatomical results, were also recorded. RESULTS The mean age of the patients was 60.7 ± 9.1 years. The mean total operative time was 121.3 ± 22.7 minutes. The mean operative time for vaginal hysterectomy, vNOTES sacrocolpopexy, and vNOTES uterosacral ligament suspension was 46 ± 11.9, 65 ± 38, 25 ± 8.2 minutes, respectively. There were no intraoperative and postoperative complications observed. The mean postoperative 24-hour visual analog scale score was 3.5 ± 1.9 for vNOTES sacrocolpopexy patients and 3.2 ± 0.9 for vNOTES uterosacral ligament suspension patients. Only one patient in the vNOTES sacrocolpopexy group had a recurrence; she experienced stage 2 anterior compartment prolapse 8 months after surgery. CONCLUSION As a treatment for apical pelvic organ prolapse, vNOTES is a feasible approach in both sacrocolpopexy and uterosacral ligament suspension.

Study Objective To compare the feasibility of opportunistic bilateral salpingectomy (OBS) at the time of vaginal hysterectomy (VH) for benign disease in patients with and without relative contraindications (RCs) to the vaginal approach and to evaluate the factors that contribute to the inability to perform OBS. Design Retrospective chart review. Setting Tertiary medical center. Patients Women undergoing hysterectomy for benign indications between November 2014 and October 2017 who were consented for either VH with or without removal of tube(s) and/or bilateral salpingectomy. Interventions RCs to the vaginal approach are defined as lack of prolapse (cervix high, cervix not visualized, cervix tucked underneath pubis, or minimal descent), enlarged uterus (≥250 g or a size of a ≥12-week uterus), nulliparity, obesity (body mass index ≥30 kg/m2), previous cesarean section (CS), known adhesions, and known adnexal pathologic condition. Measurements and Main Results A total of 258 patients underwent VH and attempted to undergo OBS within the study period; of these, 112 patients (43.4%) had no RC, and 146 patients (56.6%) had ≥1 RCs. Overall, successful salpingectomy was performed in 86.8% of patients. There was no significant difference in the rate of success in patients without or with ≥1 RCs (84.9% vs 89%, p = .15). Salpingectomy was unsuccessful in 13.2% of patients (n = 34). In a multivariable logistic regression analysis, the odds of unsuccessful OBS were 3.83 times higher in patients without prolapse (confidence interval [CI], 0.99–14.76; p = .051), 2.71 times higher in patients with obesity (CI, 1.23–5.94; p = .013), and 3.07 times higher in patients with previous CS (CI, 1.17–8.08; p = .023) as compared to patients without any relative contraindications. An enlarged uterus was associated with successful salpingectomy (odds ratio, 0.28; 95% CI, 0.08–0.94; p = .039) compared with a normal-sized uterus. When excluding enlarged uterus, patients with 2 to 3 RCs had 11.24 and 6.8 higher odds of an unsuccessful OBS than patients with no (CI, 3.73–33.87; p Conclusion OBS is associated with a high overall rate of success in patients with and without traditional RCs to VH. Lack of prolapse, obesity, and previous CS were associated with failed attempt at salpingectomy. Patients with ≥2 RCs to VH should be counseled about the high likelihood of failed salpingectomy.

Objectives Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. Methods This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. Results In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. Conclusions Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

Objective To compare the effect of same-day discharge on 30-day readmission risk after minimally invasive pelvic reconstructive surgery. Methods This retrospective cohort study included all minimally invasive pelvic reconstructive procedures with and without concomitant hysterectomy performed within a large managed care organization of 4.5 million members from 2008 to 2018. We queried the system-wide medical record for Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision codes for all included procedures and patient perioperative data. Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department (ED) visits. Perioperative data and 30-day outcomes were compared using χ for categorical variables and Kruskal-Wallis for continuous variables. We performed a multivariate logistic regression adjusting for perioperative variables and their potential effect. Results Of the 13,445 patients undergoing pelvic reconstructive surgery, 5,506 were discharged the same day and 7,939 were discharged the next day. There was no difference in 30-day readmission comparing those discharged the same day with those discharged the next day (odds ratio [OR] 0.79; 95% CI 0.60-1.03; 1.5% vs 2.0%, P=.07). Concomitant hysterectomy was performed in 6,171 individuals: There was no difference (OR 0.90; 95% CI 0.60-1.33; 1.9% vs 2.1%, P=.59) in 30-day readmission rates when comparing those discharged on the same day with those discharged the next day. We also found no difference in 30-day readmissions rates when comparing same-day with next-day discharge (OR 1.33, 95% CI 0.79-2.26; 2.8% vs 2.1%, P=.28) in (n=3,482) individuals undergoing vaginal hysterectomy. For those who did not undergo hysterectomy at the time of their prolapse surgery, there was no difference (OR 0.77; 95% CI 0.53-1.13; 1.3% vs 1.7%, P=.18) in 30-day readmission when comparing those discharged the same day with those discharged the next day. After adjustment for patient and perioperative characteristics, there was no statistically significant difference in the readmission risk for individuals with same-day discharge compared with next-day discharge among those with (adjusted odds ratio [aOR] 0.91; 95% CI 0.61-1.36; P=.63) and without (aOR 0.86; 95% CI 0.58-1.27; P=.45) a concomitant hysterectomy. For the secondary outcome of 30-day ED visits, we found no statistically significant differences when comparing same-day with next-day discharge for the entire cohort, those with concomitant hysterectomy, or when controlling for patient and perioperative characteristics. Conclusion In women undergoing minimally invasive pelvic reconstructive surgery within a large managed care organization, there is no difference in 30-day readmission or ED visit rates between those discharged the same day and those discharged the next day. When considering patient factors, same-day discharge after minimally invasive pelvic reconstructive surgery may be safe and play an important role in value-based care.

Purpose of Investigation The purpose of this study was to study the expression of adenosine diphosphate ribosylation factor GTPase-activating protein 3 (ArfGAP3) in the anterior vaginal wall of patients with pelvic organ prolapse (POP). Materials and Methods From July 2016 to July 2018, the anterior vaginal wall of 31 POP patients (pelvic organ prolapse quantification [POP-Q] II-III [n = 10] and POP-Q IV [n = 21]) with pelvic floor dysfunction-related symptoms who underwent vaginal hysterectomy were enrolled in POP group in the Department of Gynecology of Wuhan University People’s Hospital. The anterior vaginal wall of 28 non-POP patients who underwent vaginal hysterectomy was selected as control group. The expression of 3 groups was determined by immunohistochemical staining, Western blotting, and quantitative real-time fluorescence polymerase chain reaction. Results The expression levels of ArfGAP3 of POP-Q II-III and POP-Q IV groups were lower than the control group (P < 0.05), and there were significant differences between POP-Q II-III and POP-Q IV groups (P < 0.05). Conclusions The expression of ArfGAP3 in the anterior vaginal wall of POP patients decreased, which was related to the pathogenesis and clinical grading of POP.

Purpose: To evaluate the post-hysterectomy vault prolapse (PHVP) rates performed using different methods of vaginal total hysterectomy (VTH). Methods: A total of 251 women who underwent VTH with/without concomitant surgeries between January 1986 and December 2001 in a tertiary center. Thirty-eight women were excluded due to not only a vaginal approach. Of the remaining 213 women, 129 and 84 underwent VTH via the Tsuzi method with residual uterine ligament ligations (ligations group) and traditional VTH (without ligations group), respectively. The χ2 and Mann-Whitney U tests were applied appropriately. The cumulative percentages of women without PHVP were calculated over time and compared using Kaplan-Meier curves and log-rank tests. A p value of less than 0.05 was considered statistically significant. Results: Compared to the without ligations group, women in the ligations group had longer operation time (115.9 ± 37.1 vs. 103.3 ± 41.4 min, p = 0.002) and more blood loss (217.4 ± 137.8 vs. 148.2 ± 149.0 mL, p

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 (

Background. LACC trial demonstrated inferiority of laparoscopic approach for the treatment of early-stage cervical cancer. There are still limited data from retrospective trials regarding whether survival outcomes after laparoscopic radical hysterectomy are equivalent to those after open abdominal radical hysterectomy. In this study, we present results of combined vaginal radical laparoscopic hysterectomy in the treatment of early-stage cervical cancer. Methods. This retrospective study was carried out at the Department of Gynecology in Mathilden Hospital (Herford, Germany). Between January 2008 and April 2018, all the patients with invasive cervical cancer who underwent combined vaginal assisted radical laparoscopic hysterectomy (VARLH) without the use of any uterine manipulator were enrolled to the study. Results. A total number of 124 patients with diagnosis of invasive cervical cancer were enrolled in the study. All of the patients underwent minimally invasive surgery and were divided according to FIGO 2019: stage IA (25.9%), IB1 (25.0%), IB2-IIB (28.4%), and III/IV (20.7%). Overall, the mean age of the patients was 51.84 years. After a study collection, a median follow-up was 45.6 (range 23.7-76.5) months. The 3- and 5-year disease-free survival rates for early-stage cervical cancer were both 98%, and the 3- and 5-year overall survival rates were 100% and 97%, respectively. We have not observed any recurrence in our study group of patients with early-stage cervical cancer. Conclusions. Combined VARLH can be considered a safe and effective procedure for the treatment of early-stage cervical cancer. Surgical strategy with oncological principles determines the quality and long-term success of the operation in early cervical cancer regardless of laparoscopic approach.

PMID:31909461 Objectives: The study aimed to examine the predisposing factors that play a role in the development of complications in patients undergoing vaginal hysterectomy. Material and methods: This retrospective analysis was performed on data provided from 239 patients who underwent vaginal hysterectomy due to uterine prolapse at a single centre between January 2008 and August 2018. Complications were defined according to Clavien-Dindo classification of complications. The patients were divided into two groups: with and without complications. We built a model using multivariable logistic regression to examine the relationships between complications and five candidate predictors. Results: Intra/postoperative complications developed in 30 patients, and the complication rate was found to be 12.5%. 87.2% of the reported complications were classified as Grade ≤2 according to Clavien-Dindo system. It was found that complications were associated with factors such as intraoperative concurrent salpingo-oophorectomy [Odds ratio (OR): 1.24 (1.1.1.4)], low preoperative haemoglobin [OR: 0.96 (0.94.0.98)], uterine weight [OR: 2.69 (2.62.2.76)], and long operation time [OR: 1.04 (1.02.1.07)]. History of pelvic surgery was not found to increase complication rate [OR: 1.11 (0.96.1.27), p = 0.13]. Our multiple logistic regression model correctly classified 74% of participants within the Receiver Operating Characteristic (ROC) curve. Conclusions: Preoperative anaemia, large uterus and concomitant adnexectomy were found to be factors associated with complications during and after vaginal hysterectomy for pelvic organ prolapse.

Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period.This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database.This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses.In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3-19) and varied significantly based on type of injury (P.01) with ureteral obstruction (6; interquartile range, 2-16) recognized earlier than ureteral fistula (12; interquartile range, 7-21) and bladder fistula (14; interquartile range, 4-23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21-3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16-3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26-3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders.Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period.

Hysterectomy is one of the most common operations performed by the gynecologists second to caesarean section. Hysterectomies are done vaginally, laparoscopically or abdominally. This study has been conducted to compare the complications of abdominal hysterectomy with non-descent vaginal hysterectomy with an aim to establish a safer, superior and lesser complication for the patients.This is a cross sectional study conducted at Kathmandu Model Hospital over the period of one year among 70 women. Women according to inclusion criteria were randomly allocated into two groups; 35 women in group 1 underwent non-descent vaginal hysterectomy and 35 in group 2 underwent total abdominal hysterectomy. Demographic data, intraoperative blood loss, intraoperative complications, operation time, postoperative complications, pain, and hospital stay was recorded and analyzed using statistical tool.. Results: The average age of the women was 45.77±6.33 years. Median blood loss (p=0.033) and hospital stay (p=0.005) was significantly low in group 1 as compare to group 2. Mean pain score at discharge (p=0.0005) and follow-up (p=0.0005) was also significantly less in group 1 as compared to group 2. Overall rate of complication was rare and not statistically significant between groups (p=0.643). Rate of wound infection was 5.7% that was observed in group 2, Vault infection 5.7% in group 1, UTI in 2 cases (5.7%) and paralytic ileus was found in 1 case in group 2.Non-descent vaginal hysterectomy is safe, effective and feasible procedure compared with abdominal hysterectomy. Less complications, faster operating time and easy recovery post operatively makes this a patient friendly mode of hysterectomy.

OBJECTIVE To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse. METHODS We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension. RESULTS The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P

Study Objective: To evaluate the impacts of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) on the hysterectomy route and concomitant adnexal surgery at the time of vaginal hysterectomy (VH). Material and Methods: This retrospective study analyzed all hysterectomies performed for benign indications between 1 January 2017 and 31 December 2019. The period preceding the first case of VH and vNOTES BSO was considered as Pre-vNOTES. The period starting from the date of the first case was considered as Post-vNOTES. The rates per route of hysterectomy and the rate of concomitant adnexal surgery at the time of VH were compared between the two periods. Results: In hysterectomies performed by surgeons who implemented vNOTES, the proportion of the vaginal route increased from 40.1% to 94.3% (P-value < 0.001); the abdominal route decreased from 37.4% to 3.2% (P-value < 0.001); and the laparoscopic route decreased from 22.5% to 2.5% (P-value < 0.001). The rates of concomitant adnexal procedures performed at the time of VH also showed significant changes. While 39.7% of patients did not undergo any concomitant adnexal surgery during the Pre-vNOTES period, this rate dropped to 8.1% after the implementation of vNOTES (P-value < 0.001). Similarly, the rate of bilateral salpingectomy dropped from 49.3% to 14.2% (P-value < 0.001), whereas the rate of BSO increased from 6.8% to 75% (P-value < 0.001). Conclusion: Implementation of vNOTES has led to a significant increase in the rate of VH and the rate of concomitant BSO at the time of VH. (C) 2021 Elsevier Masson SAS. All rights reserved.

Rationale: Vesicovaginal fistula (VVF) most commonly occurs due to iatrogenic injury during surgery or obstructed labor. We report a rare case of a patient with severe pelvic organ prolapse who developed VVF even though pessary had not been used. Patient concerns: A 63-year-old postmenopausal woman, para 3 (all spontaneous vaginal deliveries), complained of vaginal bulging sensation and involuntary urinary leakage for 3 years. Diagnosis: Stage IV uterine prolapse with VVF. Interventions: She underwent transvaginal VVF repair combined with total vaginal hysterectomy and sacrospinous ligament fixation. The postoperative course was uncomplicated. Outcomes: The patient remained free of complications during the 1-year follow-up. Lessons: This case illustrates the point that patients with pelvic organ prolapse (POP) should be treated promptly and careful follow-up should be conducted. Clinicians should be aware of the symptoms of VVF to ensure its early diagnosis and treatment.

To determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure.A retrospective cohort study (Canadian Task Force classification II-2).An academic medical center.All women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study.Total vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy.A total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%-88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05-1.20; p.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07-1.27; p.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy.In patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.

We compared vaginal hysterectomy with bilateral sacrospinous fixation plus an anterior polyvinylidene fluoride mesh versus abdominal sacrocolpopexy for the treatment of primary apical prolapse in postmenopausal women. A prospective, randomized, single-blind, parallel study [Registro Brasileiro de Ensaios Clinicos (REBEC) trial register code RBR-7t6rg2] was performed from October 2015 to May 2016. A total of 71 postmenopausal women with advanced pelvic organ prolapse (POP) and undergoing surgery were randomized to the abdominal sacrocolpopexy (ASC) (n = 36) or the vaginal sacrospinous fixation with anterior mesh (VSF-AM) (n = 35) groups. Pelvic Organ Prolapse Quantification (POP-Q) system classification was performed for objective assessment, and the International Consultation on Incontinence Questionnaire–Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) questionnaires were filled out for subjective evaluation by women before and 1 year after surgery. All procedures were performed by a single surgeon. Both groups had improvement in almost POP-Q points (except for vaginal length in the VSF-AM group) and all ICIQ scores. The ASC group had a longer operative time (129 versus 117 min, p = 0.0038) and duration for return to activities (103 versus 57 days, p

Objectives: The extraperitoneal uterosacral ligament suspension (ULS) can be performed during the removal of the uterus in vaginal hysterectomy to prevent cuff prolapse. In this study, we evaluated...

This study aimed to evaluate the efficacy of the ring pessary compared with surgery as a primary treatment for advanced pelvic organ prolapse (POP) in non-hysterectomized, postmenopausal women. Our starting hypothesis was that the pessary is as effective as and less risky than surgery. This study was a prospective observational study, which recruited 171 women with symptomatic advanced POP in a tertiary hospital for 30 months. They were treated according their preference with either surgery [77/171 (45.0%)] or vaginal ring pessary without support [94/171 (55.0%)]. The primary outcomes included the discontinuation of pessary use and the incidence of recurrent prolapse throughout the study. Secondary outcomes included complications categorized according to Clavien-Dindo classification. Descriptive statistics were used for demographic data. The mean and standard deviation were calculated for continuous variables, and continuity correction tests, Mann-Whitney U tests, and Fisher’s exact tests were used for categorical variables. There was successful use of a pessary in 84.4% (76/90) of cases, and 89.6% (69/77) of patients did not have prolapse recurrence in the surgical group (>POP-Q 2). In the pessary group, the adverse event rate was 31.6%, and all were Clavien-Dindo grade I. Thirty patients [30/77 (39.0%)] had complications in the surgery group: 14.3% were Clavien-Dindo grade I (11/77), 10.4% were grade II (8/77), and 14.3% were grade III (11/77). The pessary is effective and has mild adverse events in non-hysterectomized, postmenopausal women with advanced POP.

Objectives To assess the effect of monopolar coagulation vs cut mode during colpotomy at total laparoscopic hysterectomy on vaginal cuff dehiscence. Study design We conducted this randomized controlled trial at a university hospital’s department of obstetrics and gynecology from September 2016 through January 2018. Enrolled women were randomized 1:1 to monopolar coagulation or cut modes during colpotomy. We followed up 100 participants in the coagulation arm and 99 in the cut arm for ongoing data collection for 12 weeks after surgery. Exclusion criteria were suspicion of pregnancy, previous radiation therapy, uterine size exceeding 20 weeks’ gestation, contraindication for high intraabdominal pressure, clinical advanced stage malignant disease, and conversion to laparotomy before completion of colpotomy. Differences between groups for categorical variables were analyzed by chi-square test and the comparisons of continuous variables between groups were analyzed by Student’s t-test Results The study groups were comparable regarding demographics and perioperative parameters. The rate of vaginal cuff dehiscence in coagulation group (1%) was similar to that of cut group (0%) (p = 0.995). The other vaginal cuff related complication rates were also similar. Conclusion Monopolar coagulation and cut modes during colpotomy at total laparoscopic hysterectomy have similar vaginal cuff dehiscence rates and both energy modes seem acceptable for colpotomy.

OBJECTIVE Receptors for estrogen and progesterone are present in the pelvic floor, and therefore, postmenopausal hormone therapy may affect its function. We compared the former use of estradiol-progestogen postmenopausal hormone therapy in nonhysterectomized women with a uterine prolapse surgery (N = 12,072) and control women (N = 33,704). METHODS The women with a history of uterine prolapse operation were identified from the Finnish National Hospital Discharge Register, and the control women from the Finnish Central Population Register. The use of hormone therapy was traced from the national drug reimbursement register, and the odd ratios with 95% CIs for prolapse were calculated by using the conditional logistic regression analysis. RESULTS The women with uterine prolapse had used hormone therapy more often than control women (N = 4,127; 34.2% vs N = 9,189; 27.3%; P

Objective To determine the 30-day morbidity rate after hysterectomy for benign disease and identify predictors of 30-day morbidity. Methods A retrospective study was conducted among women undergoing hysterectomy for benign indications between January 1, 2010, and December 31, 2015, at Konkuk University Hospital, South Korea. Multivariable regression analysis identified independent factors for morbidity. Results 1609 women were included. 30-day morbidity rates were 4.5% (n=72) for the whole cohort: 7.5% (28/371), 3.2% (22/686), and 4.0% (22/552) for abdominal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), and vaginal hysterectomy, respectively. The most common 30-day postoperative morbidities were urinary complications (1.2%, 20/1609), wound infection (0.9%, 14/1609), and blood transfusion more than 4 units (0.7%, 11/1609). In multivariate regression analysis, Charlson comorbidity index of 2 or more, operative time, and estimated blood loss were independently associated with morbidity. Propensity score-matching indicated no difference in morbidity rates for the abdominal hysterectomy and LAVH or vaginal hysterectomy groups (P=0.351), whereas the LAVH or vaginal hysterectomy groups were more strongly associated with operation time, estimated blood loss, and length of postoperative hospital stay. Conclusion Comorbidity index, operative time, and blood loss were independently associated with morbidity following hysterectomy. These findings supported the preoperative optimization of comorbidities and the appropriate selection of surgical approaches.

Objective To compare the effect of abdominal and vaginal hysterectomy with or without bilateral salpingo-oophorectomy on female sexuality. Methods Perimenopausal, sexually active, aged 45–50 years women who underwent abdominal or vaginal hysterectomy with or without bilateral salpingo-oophorectomy due to benign indications were included in this retrospective study. For the assessment of preoperative and postoperative female sexual function, Turkish validated Female Sexual Function Index form was used. Results Of the study population, 82 women (Group A) underwent hysterectomy + bilateral salpingo-oophorectomy and 78 women (Group B) underwent hysterectomy-only operations. The groups were statistically similar in terms of mean age, number of gravida and parity, body mass index, duration of postoperative evaluation, type of hysterectomy and presence of preoperative female sexual dysfunction. Both in Group A and B, postoperative total Female Sexual Function Index scores increased significantly compared to preoperative total scores. And there were no differences between the groups regarding the total preoperative and postoperative Female Sexual Function Index scores. However, postoperative arousal and orgasm scores were higher while pain score was lower in Group B than in Group A. Conclusion Abdominal and vaginal hysterectomy with or without bilateral salpingo-oophorectomy for benign causes positively affect female sexuality in general. But, premenopausal bilateral oophorectomy may cause more pain during intercourse, decreased libido and orgasm than ovary conservation.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a minimally invasive, scar-free technique that uses a vaginal colpotomy to access the peritoneal cavity. Hysterectomy via vNOTES has shown to be technically feasible and safe, with shorter hospital stay and lower postoperative pain scores. Moreover, vNOTES adds the advantages of endoscopy to those of vaginal surgery and thereby broadens the indications of a conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, as vaginal accessibility can be severely reduced in virgin women. Therefore, cases of vNOTES hysterectomy in virgin patients have never been reported in the literature. The objective of this study is to assess the technical feasibility and safety of hysterectomy in virgin women. We performed a retrospective analysis of patient files of all vNOTES hysterectomies performed on virgin women in our centre (Imelda Hospital, Bonheiden, Belgium) from July 2016 until June 2020 (N = 9). Despite limited vaginal accessibility, vNOTES hysterectomy was successfully performed in all nine patients, without conversion to laparoscopy or laparotomy and without clinically relevant complications. In this first IDEAL stage 1 study, vaginal NOTES hysterectomy appears to be technically feasible and safe in virgin women.Impact statementWhat is already known on this subject? Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging, minimally invasive technique that offers a safe alternative to laparoscopy and open surgery. Besides better cosmetics (scar-free technique), advantages of vNOTES hysterectomy include shorter hospital stay and less postoperative pain compared to laparoscopic hysterectomy. Moreover, vNOTES adds the benefits of endoscopy (visualisation of anatomy) to conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, because the absence of uterine descent and narrow vagina in virgins is thought to complicate the vaginal approach. Therefore, vNOTES hysterectomy has never been reported in virgin patients.What do the results of this study add? In this study, we are the first to report the feasibility of performing a vNOTES hysterectomy in virgin patients. The results show that, in experienced hands, indications for vNOTES can be broadened and include virgin women.What are the implications of these findings for clinical practice and/or further research? This first report of vNOTES hysterectomy in virgin patients is only a small but important step in the evaluation of safety and efficacy of this emerging technique. Further research is needed to assess reproducibility of the findings and to carefully determine indications and contraindications of vNOTES.

Background Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Sacrospinous hysteropexy with graft (vaginal mesh hysteropexy) is an alternative, although in 2019 the Food and Drug Administration removed this mesh product from the United States market. Objective Our objective was to compare the efficacy and adverse events of these 2 procedures. Study Design At 9 clinical sites in the United States National Institutes of Health and National Institute of Child Health and Human Development Pelvic Floor Disorders Network, 183 postmenopausal women requesting vaginal surgery for symptomatic uterovaginal prolapse were enrolled in a multisite randomized superiority clinical trial, comparing a sacrospinous hysteropexy with graft (hysteropexy) with a vaginal hysterectomy with uterosacral ligament suspension (hysterectomy). Participants consented to remain masked to treatment assignment for the study duration. Study visits were conducted at 6-month intervals through 60 months. The primary treatment failure composite outcome (retreatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival modeling. Secondary outcomes included complications or adverse events, individual anatomic measures of the pelvic organ prolapse quantification examination, and presence, severity, and impact and bother of prolapse, urinary, bowel, and pain symptoms as measured by validated questionnaires. The 3-year published results suggested better primary outcomes with sacrospinous hysteropexy with graft, but the differences were not statistically significant (P=.06). This study reports the 5-year outcomes. Results A total of 183 women with a mean age of 66 years were randomized between April 2013 and February 2015; 93 were randomized to hysteropexy and 90 were randomized to hysterectomy. Notably, 175 were included in the trial, and 156 (89%) completed the 5-year follow-up. The primary outcome showed fewer failures for hysteropexy than hysterectomy through 5 years (adjusted hazard ratio, 0.58; 95% confidence interval, 0.36–0.94; P=.03), with failure rates of 37% vs 54%, respectively, resulting in a difference of −18% (95% confidence interval, −33% to −3%) at 5 years. With the exception of the Urogenital Distress Inventory, no group differences were demonstrated in patient-reported pelvic floor symptoms, prolapse symptoms, bowel function symptoms, general quality of life, body image, or pelvic pain. At their last visit through 5 years, 70% of participants (129 of 183) reported they remained masked to their treatment with no difference in masking between groups. Adverse events for hysteropexy vs hysterectomy included mesh exposure (8% vs 0%), granulation tissue after 12 weeks (1% vs 12%), and suture exposure after 12 weeks (3% vs 21%), respectively. Conclusion Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, sacrospinous hysteropexy with graft resulted in a lower composite failure rate than vaginal hysterectomy through 5 years. There were no meaningful differences in patient-reported outcomes between groups. Our results suggest that this vaginal mesh hysteropexy procedure should be made available to patients.

Background Although transvaginal natural orifice transluminal endoscopic surgery (NOTES) is gaining importance, knowledge on transvaginal NOTES procedures in gynecologic practice is limited. Objective We aimed at evaluating the feasibility and safety of performing hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) via transvaginal NOTES using a self-developed multichannel abdominal port and vaginal support ring. Study design A prospective, single-center, cohort pilot study was conducted from May to December 2017 in patients with benign uterine diseases or endometrial atypical hyperplasia or cervical intraepithelial neoplasia (n = 30) scheduled for laparoscopic hysterectomy. The procedure was performed using a self-developed five-channel port and a vaginal support ring. Results Hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) in all 30 cases (mean age: 51.43 ± 4.60 years and body mass index: 23.42 ± 1.45 kg/m2 ) were successfully performed completely under transvaginal NOTES. Mean operation time was 95.90 ± 14.60 minutes and mean blood loss during the procedure was 52.50 ± 19.20 mL. Average weight of specimen was 79.97 ± 35.48 g. Only one complication of bladder injury was noted and was rectified accordingly. Visual Analog Score (VAS) at first day after operation was 2.70 ± 0.72. After follow-up for 4.50 ± 1.85 months, all the patients' vaginal stump healed well without scar formation. Conclusion Our study showed that use of multichannel abdominal port could make laparoscopic instruments easier to fix and operate wherein the vaginal support ring reduces the leakage of carbon dioxide pneumoperitoneum. There was no scar on the abdomen and VAS was much lower. This study also demonstrated cosmetic benefits and rapid postoperative recovery.

Background Symptomatic prolapse impairs quality of life. Health-related quality of life (HRQoL) is considered an important outcome of pelvic organ prolapse (POP) surgery. However, it is rarely reported, and measures are inadequately used. Thus, studies reporting patient-reported surgical outcomes in low-income contexts are needed. This study aims to evaluate the effect of prolapse surgery on patient HRQoL and determine the predictive factors for change in HRQoL. Methods A total of 215 patients who had prolapse stage III or IV were enrolled. Patients underwent vaginal native tissue repair, and their HRQoL was evaluated at baseline, 3 and 6 months postoperatively. Effect of surgery on subjective outcomes were measured using validated Prolapse Quality of Life (P-QoL-20), Prolapse Symptom Score (POP-SS), Body Image in Prolapse (BIPOP), Patient Health Questionnaire (PHQ-9), and Patient Global Index of Improvement (PGI-I) tools. A linear mixed-effect model was used to compare pre- and postoperative P-QoL scores and investigate potential predictors of the changes in P-QoL scores. Results In total, 193 (89.7%) patients were eligible for analysis at 3 months, and 185 (86.0%) at 6 months. Participant’s mean age was 49.3 ± 9.4 years. The majority of patients had prolapse stage III (81.9%) and underwent vaginal hysterectomy (55.3%). All domains of P-QoL improved significantly after surgery. Altogether more than 72% of patients reported clinically meaningful improvement in condition-specific quality of life measured with P-QoL-20 at 6 months. An improvement in POP-SS, BIPOP, and the PHQ-9 scores were also observed during both follow-up assessments. At 6 months after surgery, only 2.7% of patients reported the presence of bulge symptoms. A total of 97.8% of patients had reported improvement in comparison to the preoperative state, according to PGI-I. The change in P-QoL score after surgery was associated with the change in POP-SS, PHQ, BIPOP scores and marital status (p Conclusions Surgical repair for prolapse effectively improves patient’s HRQoL, and patient satisfaction is high. The result could be useful for patient counselling on the expected HRQoL outcomes of surgical treatment. Surgical service should be accessible for patients suffering from POP to improve HRQoL.

OBJECTIVE The objective of this study was to measure the anatomical distance from the cervicovaginal junction to the uterovesical peritoneal reflection (CJ-PR). METHODS A total of 120 hysterectomy patients were selected as study subjects. The uterus was removed, and the CJ-PR distance was immediately measured. For total vaginal hysterectomy, measurement was performed intraoperatively. The cervical length was also measured postoperatively. RESULTS The median (interquartile) CJ-PR distance for all subjects was 3.3 (2.9-3.7) cm. Comparison of premenopausal and postmenopausal women without prolapse revealed median CJ-PR distances of 3.3 (3.0-3.6) cm and 3.0 (2.6-3.4) cm, respectively. The CJ-PR distance was longer in women with prolapse (4.6 [3.7-5.6] cm) than in those without prolapse (3.2 [2.8-3.6] cm). The median cervical lengths were 3.1 (2.7-3.6) cm for postmenopausal patients without prolapse and 4.4 (3.6-5.8) cm for postmenopausal patients with prolapse. CONCLUSIONS Knowledge of the CJ-PR distance may help gynecologists predict how far the uterovesical PR is from the anterior vaginal incision.

The aim of this study was to determine when women are at risk for recurrent pelvic organ prolapse (POP).From 2010 to 2018, all women with symptomatic prolapse, Pelvic Organ Prolapse Quantification (pop-Q) stage 2 in at least one compartment and prolapse surgery were included. The primary outcome measure was POP recurrence. Kaplan-Meier estimates were calculated, survival curves were created, and differences in survival curves were tested with log-rank test. Cox proportional hazard regression was used to investigate associations between recurrence and the number and type of involved compartment(s) and type of surgery.Forty-six (16.8%) out of 274 patients had POP recurrence during a mean follow-up time of 55 ± 32 months. The mean age was 64 ± 12 years. The hazard of recurrence increased the most in the first 2 years after POP surgery, flattened in years 3 and 4 and remained almost stable in the years thereafter, regardless of the site and number of involved compartment(s). The hazard of recurrence over time seemed the largest when all three compartments were involved. However, there was no statistically significant difference in recurrence between the numbers of (p = 0.65) or in the combination of involved compartments (p = 0.19). There was no difference in POP recurrence over time between prolapse repair with either sacrospinous ligament fixation or vaginal hysterectomy (p = 0.48).Women are at the highest risk of POP recurrence in the first 2 years after POP surgery independent of the number or combination of involved compartment(s).

OBJECTIVE To assess a multiple-tier intervention to increase vaginal hysterectomy rates. METHODS We performed a cohort study assessing hysterectomy performance before and after implementation of a multiple-tier intervention to increase vaginal hysterectomy rates at a single tertiary care medical center. This intervention involved resident and attending education and simulation, professional development, design of a clinical pathway to assist in hysterectomy decision making, and development of a surgical mentorship program. RESULTS Data from 698 hysterectomies (253 preintervention and 445 postintervention) were included. The preintervention time period extended from January 1, 2016, to December 31, 2017 (24 months), and the postintervention period from January 1, 2018, to February 28, 2020 (26 months). The intervention was implemented over the month of December 2017 but was not complete until January 1, 2018. The preintervention and postintervention cohorts were similar in most demographic and clinical aspects. Postintervention, the proportion of vaginal hysterectomies was higher (26.5% vs 5.5%, odds ratio 6.2, 95% CI 3.52-11.35), including in those performed for reasons other than prolapse (6.8% vs 0%, P

International audience; Introduction: Inserts Essure® were used as a definitive sterilization method from 2001 to 2017. They have been used for more than 750,000 procedures. Gynecological or extra gynaecological adverse events have been reported by patients. The objective of the study is to evaluate the resolution of symptoms attributed to Essure® micro-inserts after surgical removal.Methods: Monocentric retrospective study. Patients who had surgical removal of Essure® micro-inserts between January 2017 and April 2019 were included. The removal was performed by bilateral salpingectomy with cornuectomy by laparoscopy or vaginal hysterectomy. Symptoms were reported preoperatively, 4-8 weeks after withdrawal (early assessment) and 6-24 months after withdrawal (later assessment).Results: Ninety patients had a surgical removal of Essure® micro-inserts. Fifty-two vaginal hysterectomies and thirty-five laparoscopic salpingectomies were performed. The main symptoms reported are pelvic pain (70 %), fatigue (66.7 %) and heavy bleeding menstruations (53.3 %). One month after surgery, 46.7 % of patients have a major improvement of symptoms and 51.1 % a partial resolution. The major improvement rate is not significantly different between laparoscopic salpingectomy and vaginal hysterectomy (51.5 % versus 42.3 %) (p = 0.23). At 24 months, results improved with 83.3 % major improvement.Conclusion: Surgical removal may be effective for treating most women with attributed device symptoms. Vaginal hysterectomy and laparoscopic salpingectomy with cornuectomy seem to have an equivalent rate for the resolution of extra-gynecological symptoms.

The aim of this study was to determine if preoperative medication administration is associated with postoperative urinary retention (PUR) after urogynecologic procedures and identify preoperative and intraoperative factors that are predictive of PUR.A retrospective review of patients who underwent prolapse and/or incontinence surgery was performed. The primary outcome was PUR, defined as postoperative retrograde void trial with postvoid residuals of greater than 100 mL. Bivariate analysis was performed to compare demographics and preoperative and intraoperative characteristics of women with and without PUR, and multivariable logistic regression modeling was used to identify independent predictors of PUR.Of women in this cohort, 44.8% (364/813) had PUR. There were no significant differences in preoperative medication administration in women with and without PUR. Age older than 60 years (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.09-2.02), combined prolapse and incontinence surgery (aOR, 1.84; 95% CI, 1.29-2.62), vaginal hysterectomy (aOR, 1.66; 95% CI, 1.66-2.38), and procedure time (aOR, 1.01; 95% CI, 1.00-1.01) were associated with increased odds of PUR, whereas laparoscopic sacrocolpopexy was associated with lower odds (aOR, 0.22; 95% CI, 0.10-0.46).Although preoperative medication administration was not associated with PUR, other clinically important variables were age older than 60 years, vaginal hysterectomy, incontinence and prolapse surgery, or longer procedure time. Sacrocolpopexy reduced the odds of PUR by approximately 80%. These factors may be useful in preoperative and postoperative counseling regarding PUR after urogynecologic surgery.

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal natural orifice transluminal endoscopic surgery (NOTES) technique for performing high uterosacral ligament suspension (HUS). Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Interventions A 58-year-old G2P2, NSVDx2 with stage III anterior vaginal prolapse, stage II uterine prolapse, and posterior vaginal prolapse. The preoperative vaginal length was 7-cm. Transvaginal NOTES is a creative yet difficult approach that averts an abdominal incision while simultaneously providing enhanced visualization in comparison with traditional vaginal surgery [1] . However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and bilateral salpingo-oophorectomy was subsequently performed. The following key techniques were used to perform NOTES-HUS: tagging the sutures for bilateral uterosacral ligament before single-site port placement, identifying the ischial spine and ureters, pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament, grasping and lifting the uterosacral ligament while placing a suture, and giving the suture a tug after placement to confirm the correct location 2 , 3 , 4 . The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 5-cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion Transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. There is an increased cost to using laparoscopically assisted NOTES surgery as well as a risk of pneumoperitoneum. Applying the tips and tricks presented here, such as tagging the uterosacral ligament before port placement and so on, the challenging transvaginal NOTES-HUS technique can be performed efficiently and safely.

Aim To investigate whether there is a significant difference among the patients who underwent vaginal hysterectomy with sacrospinous ligament fixation (VH + SSLF), laparoscopic hysterectomy with sacrocolpopexy (LH + SCP) and abdominal hysterectomy with sacrocolpopexy (AH + SCP) in terms of sexual function and quality of life. Material and Method Sixty-five patients undergoing vaginal hysterectomy with sacrospinous ligament fixation (VH + SSLF), laparoscopic hysterectomy with sacrocolpopexy (LH + SCP) or abdominal hysterectomy with sacrocolpopexy (AH + SCP) participated in the study. The Quality of Life Scale and Sexual Function Scale Index (PISQ-12) were used to see whether there is a significant difference among the three groups (VH + SSLF, LH + SCP, AH + SCP) at least 1 year after surgery. The Pelvic Floor Distress Inventory-20 (PFDI-20) Scale consisting of Pelvic Organ Prolapse Distress Inventory (POPDI-6), Urinary Distress Inventory (UDI-6), and Colorectal-Anal Distress Inventory (CRADI-8) was used to evaluate the functional outcomes. Results The participants had a mean age of 60 ± 8.79 years. The mean PFDI-20 score in the VH + SSLF groups is higher than that in the AH + SCP group (p = 0.047). There is no significant difference among three VH + SSLF, LH + SCP and AH + SCP groups regarding scores of POPDI-6, UDI-6, CRADI-8, and PISQ-12. Conclusion In the present study, it was concluded that AH + SCP group had a higher quality of life than the VH + SSLF group did while the sexual function was not affected significantly by the vaginal or abdominal surgical procedures. The pelvic surgeon should skillfully choose different prolapse surgical techniques to tailor the surgical treatment to the patient's needs.

Hysterectomy for benign indications has profound effects on both anatomical and physiological pelvic floor and vaginal properties. Vaginal tactile imaging (VTI) enables the quantification of pelvic floor and vaginal biomechanical properties; this enables objective evaluation of various pelvic floor functions. The purposes of this study were to evaluate via VTI, the changes in vaginal elasticity, mobility and strength, before and after hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and high utero-sacral ligament suspension (USLS); and to assess associations with sexual function. The objective of the current study was to evaluate the effect of these procedures on vaginal elasticity and sexual function.This prospective cohort study included women who underwent hysterectomy by vNOTES and USLS for the treatment of pelvic organ prolapse (POP). All the women underwent both pre- and postoperative VTI and sexual function evaluation. Vaginal elasticity and wall mobility, and the contraction strength and tone of levator muscles, were measured prior to and 6 months following surgery using VTI.A total of 23 women, mean age 56.5 years, with stage 3-4 POP participated. Vaginal elasticity increased from 27.3 ± 8.8 to 34.8 ± 12 (P0.05) and Female Sexual Function Index (FSFI) scores increased from 22.17 ± 1.62 to 28.66 ± 1.51 (P0.05). No correlation was observed between these results. A statistically significant decrease in the mobility of the anterior vaginal wall was demonstrated, from 7.98 ± 10.6 to 0.83 ± 7.5 (P0.0001).VTI showed improvements in vaginal elasticity, mobility and FSFI scores following hysterectomy and POP repair performed by vNOTES.

Natural orifice transluminal endoscopic surgery (NOTES) is a minimally invasive surgical technique that uses the natural orifices of the human body such as the vagina (vNOTES) in order to access the abdominal cavity. Currently, the vNOTES hysterectomy technique is carried out on benign indication such as dysfunctional blood loss, uterine myomatosis or adenomyosis. During surgery, the surgeon and the assistant are able to operate in a better ergonomic position than at a total laparoscopic or vaginal hysterectomy. In addition, they have a better view of the anatomical structures in the operative field and therefore fewer peroperative complications occur. The vNOTES hysterectomy procedure has been carried out at the Zuyderland Medical Centre, Heerlen, the Netherlands, since August 2019 to the satisfaction of both patients and surgeons.

Objectives: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive technique in benign gynaecologic surgery whereby surgical access to the peritoneal cavity is achieved through natural orifices, namely through a vaginal colpotomy. Experience in repeat vNOTES cases is limited and so far, repeat vNOTES cases have not been described in the literature. The purpose of this study was to demonstrate the feasibility of vNOTES hysterectomy in women with a history of previous vNOTES adnexal surgery. Design: We performed a retrospective cohort study of the first 11 repeat vNOTES cases in our centre. All vNOTES procedures, primary adnexal surgery as well as repeat vNOTES hysterectomy, were performed by one surgeon (J.B.). Materials, Setting, Methods: Between March 2016 and May 2020, 11 patients underwent a vNOTES hysterectomy after prior vNOTES adnexectomy or cystectomy in Imelda Hospital, Bonheiden, Belgium. Relevant patient characteristics and outcome data were collected after written informed consent. Results: Median age was 49 years (range 44–65) at the moment of the first vNOTES procedure. Two patients had one or more caesarean sections in history, and 2 women were nulliparous. Median interval between primary and repeat vNOTES procedure was 15 months (range 0.8–37 months). All patients underwent a vaginally assisted NOTES hysterectomy (VANH) as repeat vNOTES procedure. Performing a colpotomy and entering the peritoneal cavity after prior vNOTES was technically feasible in all cases. All VANHs were successfully performed. There were 3 minor complications after repeat vNOTES, of which one was anaesthesia-related. The 2 complications associated with the surgical procedure were both cystitis. In one of these 2 patients, there were high post-void residues, which were easily managed by bladder training. There were no conversions to laparoscopy or laparotomy, neither serious nor life-threatening complications. No ureteric, bladder, or intestinal injuries have occurred. Limitations: The retrospective design and small sample size are the main limitations of this study. Moreover, the follow-up period of the most recently operated patients was too short to draw conclusions on long-term outcomes, including sexual function. Conclusions: In all patients in this case series, vNOTES hysterectomy after prior vNOTES adnexal surgery was successfully performed. Large-scale prospective trials with long-term follow-up are needed to evaluate the safety and feasibility of multiple consecutive vNOTES procedures in 1 patient.