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Objectives At the time of controversies on surgical treatment of pelvic organ prolapse, our aim was to describe an effective technique of hysterocolpectomy with colpocleisis for elderly patients not wishing to maintain vaginal sexual activity and present mid-term results including pelvic floor symptoms and quality of life, patient satisfaction and surgical complications using validated scores. Study design We conducted a retrospective study of all patients having undergone this surgery between June 2006 and June 2016. Women were examined using POP-Q classification and completed validated questionnaires concerning symptoms and quality of life before and after the surgery. Patient satisfaction was assessed using the PGI-I. Complications were described according to the Clavien-Dindo classification. Results During the 10-year period, 37 women underwent the surgery with a mean age at surgery of 81.2 years (range: 61–93 years). One per-operative complication occurred (a rectal wound that was sutured) and five Clavien-Dindo grade 3b postoperative complications. Three repeat operations were necessary within 15 days; one suburethral sling had to be lowered because of urinary retention; one tension-free vaginal tape had to be unilaterally sectioned for acute urinary retention; and one woman presented a pararectal abscess requiring surgical drainage. The mean duration of hospitalization was 5.5 (+/-4.2) days. The mean follow-up time was 44.1 (±30.1) months. All symptoms and quality of life scores decreased significantly after the surgery and patient satisfaction was good (PGI-I score = 1.55 +/-0.8). Conclusions Hysterocolpectomy with colpocleisis appears to be an effective treatment with a high level of patient satisfaction among the elderly.

STUDY OBJECTIVE: The findings of previous studies have been inconsistent as to whether benign hysterectomy via minimally invasive laparoscopic surgery increases the risk of vesicoureteral injury when compared with laparotomy. The objectives of our study were to (1) examine the rate of vesicoureteral injury on benign hysterectomy by the surgical approach and (2) compare the risk of vesicoureteral injury specifically between minimally invasive laparoscopic and abdominal hysterectomy on a populational level. DESIGN: Retrospective population-based observational study. SETTING: The National Inpatient Sample. PATIENTS: A total of 501 110 women who had undergone hysterectomy for benign gynecologic disease between January 2012 and September 2015 were included as follows: total abdominal hysterectomy (TAH, n = 284 365 [56.7%]), total laparoscopic hysterectomy (TLH, n = 60 410 [12.1%]), abdominal supracervical hysterectomy (Abd-SCH, n = 55 655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n = 45 620 [9.1%]), total vaginal hysterectomy (TVH, n = 34 865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH, n = 20 195 [4.0%]). INTERVENTIONS: A comprehensive risk assessment for vesicoureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing was used to compare (1) TLH versus TAH and (2) LSC-SCH versus Abd-SCH with generalized estimating equations. In a sensitivity analysis, gynecologic disease–specific injury risk and vaginal route–specific injury risk (LAVH vs TVH) were assessed. MEASUREMENTS AND MAIN RESULTS: Vesicoureteral injury was reported in 1045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas LSC-SCH had the lowest (0.10%) (p

Background: Endometrial cancer (EC) is one of the most common gynecologic tumors, with a high incidence in developed countries. Although the overall prognosis is good, some women have invasive tumors, the risk of recurrence, and death is high. The common surgical methods used in EC are total-abdominal hysterectomy (TAH), total-vaginal hysterectomy (TVH), laparoscopic-assisted vaginal hysterectomy (LAVH), and total-laparoscopic hysterectomy (TLH) including both conventional and robotically assisted. Methods: The literature search was performed in The Cochrane Central Register of Controlled Trials, PubMed, Web of Science, and Embase. The randomized controlled trials (RCTs) will be included. The search date is until June 2019. The risk of bias of included RCTs was assessed by 2 investigators according to the Cochrane Collaboration's tool. Network meta-analysis will be conducted by R software. Results: This study is ongoing and the results will be submitted to a peer-reviewed journal for publication. Conclusion: This network meta-analysis will provide clinical staff with current and reliable information on the best surgical approach for EC. Ethical approval is not applicable, since this is a network mate-analysis based on published articles. The protocol has been registered on PROSPERO under the number CRD42019128094.

This study aimed to compare the frequency and risk factors of de novo urinary incontinence (UI) following abdominal and vaginal hysterectomies for benign disease.The study included patients without incontinence history who underwent abdominal or vaginal hysterectomy for benign indications. Incontinence statuses were assessed at least one year after hysterectomies. Data for age, body mass index (BMI), parity, mode of delivery, and the types of hysterectomy and postoperative UI were recorded.The study included a total of 196 patients with mean age of 52.8±11.4 years. Of these, 149 (76%) underwent abdominal hysterectomy (AH) and 47 (24%) had vaginal hysterectomy (VH). The mean follow-up period was 1.97±1.43 years. A total of 41 (20.9%) patients were diagnosed with UI after hysterectomy. De novo UI occurrence following AH and VH was similar(p0.05). Also, UI types were not significantly found different in either group (p0.05).This study showed that de novo UI occured frequently after hysterectomies. In addition, development and types of UI following AH and VH were comparable.Abdominal hysterectomy, Urinary incontinence, Vaginal hysterectomy.Lo studio ha lo scopo di confrontare i fattori di frequenza e di rischio dell’incontinenza urinaria de novo (UI) dopo isterectomia addominale e vaginale. Sono stati incluse pazienti sottoposte ad isterectomia addominale o vaginale per indicazioni di patologia benigna senza storia pregressa di incontinenza urinaria. La situazione di incontinenza è stata valutata almeno un anno dopo le isterectomie. Sono stati riportati i dati di età, indice di massacorporea (BMI), parità e tipo di parto, tecnica dell’isterectomia e tipi di UI postoperatoria. Sono state incluse nello o studio un totale di 196 pazienti, di età media di 52,8 ± 11,4 anni. Di queste pazienti, 149 (76%) sono state sottoposte ad isterectomia addominale (AH) e 47 (24%) ad isterectomia vaginale (VH). Il periodo medio di follow-up delle pazienti è stato di 1,97 ± 1,43 anni. Un totale di 41 (20,9%) pazienti sono state diagnosticate come affette da UI insorta dopo l’isterectomia. Le pazienti hanno presentato analoga incidenza di UI de novo sia dopo isterectomia per via addominale che per via vaginale (p0.05), analogamente senza differenze significative di UI nei due gruppi (p0,05). Lo studio ha dimostrato una elevata frequenza di incontinenza urinaria dopo isterectomia in modo paragonabile dopo l’adozione della via addominale e quella vaginale. Pertanto sembra importante la valutazione preliminare dei fattori di rischio e l’adozione di procedure preventive indipendentemente dall’approccio chirurgico.

Hysterectomy is common in the management of symptomatic uterine prolapse. Vaginal wall repair is often necessary, for which vaginal mesh remains a popular option.To evaluate the risk of mesh erosion following mesh-augmented vaginal prolapse repair, with or without concomitant vaginal hysterectomy.This retrospective cohort comprised 70 women who underwent vaginal mesh-augmented pelvic organ prolapse repair from 2007 to 2010. Of the participants, 36 (51.4%) had a vaginal hysterectomy concomitant to the anterior and/or posterior vaginal mesh repair (hysterectomy group) and 34 (48.6%) underwent mesh repair without vaginal hysterectomy (no hysterectomy group).There were no inter-group differences in age, parity, menopausal state, hormonal use, or presenting symptoms. Previous prolapse repair surgery was much more common in the no hysterectomy group (29.4% vs. 5.5%, P = 0.01). Eleven patients (32.3%) in the no hysterectomy group had previously undergone hysterectomy. Anterior mesh repair was performed in 77.7% and 67.6% of hysterectomy and no hysterectomy patients, respectively. Posterior mesh repair was performed in 27.7% and 44.1%, respectively. One patient in the hysterectomy group underwent immediate removal of mesh due to infection. Surgically treated mesh erosion (limited local excision) occurred in three patients (8.3%) in the hysterectomy group (3, 16, and 18 months following surgery) and in two patients (5.8%) in the no hysterectomy group at 6 months following surgery (P = 0.67).Vaginal mesh-augmentation concomitant with vaginal hysterectomy for pelvic organ prolapse repair does not carry an increased risk of erosion.

Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations.To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time.We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed.We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P.0001 for both).The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

BACKGROUND There is limited data on the incidence of postoperative infections following hysterectomy by route of surgery. We hypothesize that vaginal hysterectomy has lower rates of postoperative infection than laparoscopic and abdominal hysterectomies. METHODS A retrospective cohort study and independent hand review of charts of participants undergoing hysterectomy at five hospitals from September 2011 through May 2015 was performed. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and were reviewed by the investigators. The primary outcome was the development of Clostridium difficile infection, urinary tract infection, surgical site infection, or yeast vaginitis within 60 days following surgery. RESULTS In total, 2742 women underwent hysterectomy: abdominal 17.5% (AH), laparoscopic 65.8% (LH), and vaginal 16.7% (VH). The composite postoperative infection rate for the four specified variables was 8.5% (232). In comparing surgical route, AH was most commonly associated with CDI (0.6%, p

Objectives: To investigate the effect of vaginal cuff closure technique in laparoscopic hysterectomy on vaginal length and female sexual functions. Material and methods: This study was conducted at a tertiary research hospital. Women who underwent laparoscopic hysterectomy were included and classified according to vaginal cuff closure technique as laparoscopic (n = 75) and vaginal route (n = 25). Vaginal lengths were measured preoperatively and at 6th month postoperatively. Golombok–Rust Inventory of Sexual Satisfaction (GRISS) was used to evaluate female sexual functions. SPSS was used for statistical analysis and the level of significance was p = 0.05. Results: Preoperative GRISS scores and vaginal lengths were similar in two groups. The shortening of vaginal length and the worsening of GRISS scores were more prominent in vaginal cuff closure group (p = 0.002, p < 0.001). The alteration in vaginal length was positively correlated with the alteration in GRISS score in vaginal and laparoscopic route groups (r = 0.800, p < 0.001; r = 0.680, p < 0.001). The risk of female sexual dysfunction increases 69.88 fold for each 1 cm shortening of vaginal length (p = 0.039). Discriminative value of postoperative vaginal length for female sexual dysfunction in patients who underwent laparoscopic hysterectomy was investigated and a cut-off value of 7.4 cm (p < 0.001) was found. Conclusions: Laparoscopic route instead of vaginal route in laparoscopic hysterectomy is preferable to preserve a better vaginal length, which may be an important factor for female sexual functions.

OBJECTIVE: To compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of benign hysterectomy to those who did not. METHODS: This was a retrospective cohort study of patients who underwent hysterectomy without a concomitant procedure for prolapse or incontinence for benign pathology with a general obstetrician–gynecologist recorded in the National Surgical Quality Improvement Program (NSQIP) targeted hysterectomy file between 2015 and 2017 were identified. The primary outcome was a delayed lower genitourinary tract injury in the 30 days after hysterectomy. Secondary outcomes included urinary tract infection and operative time. The exposure of interest was cystoscopy at the time of hysterectomy. Stratified analysis was performed by route of surgery. Bivariable tests were used to examine associations. RESULTS: We identified 39,529 women who underwent benign hysterectomy with a general obstetrician–gynecologist. Surgical approach was open (26%), laparoscopic or robotic assisted laparoscopic (46%) and vaginal or vaginally assisted (28%). Overall, 25% of women underwent cystoscopy at the time of hysterectomy, cystoscopy was more commonly performed in laparoscopic or robotic (32%) and vaginal hysterectomy (25%) as compared to open hysterectomy (11%) (p

Objective The purpose of this study was to assess the postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer and to determine risk factors of severe perioperative morbidity. Methods Data of two prospective trials on sentinel node biopsy for cervical cancer (SENTICOL I & II) were analysed. Patients having a radical hysterectomy were included between 2005 and 2012 from 25 French oncologic centers. Postoperative complications were prospectively recorded in a pre-specified analysis. Results 248 patients met the inclusion criteria. The median age was 44.5 years [25–85]. 88.7% of patients had a stage IB1 disease. There were 71.4% epidermoid carcinomas and 25% adenocarcinomas. 125 patients (50.4%) had a laparoscopic-assisted vaginal RH, 88 patients (35.5%) had a total laparoscopic RH, 26 patients (10.5%) had an open RH and 9 patients (3.6%) had a robotic-assisted RH. Sixteen patients (6.4%) had intraoperative complications. On a multivariate analysis, intraoperative complications were significantly associated with BMI >30 kg/m2. The urinary, lymphovascular and neurologic complications rates were respectively 34.3%, 20.6% and 19.8%. 31 patients (12.5%) had severe postoperative complications (Clavien-Dindo ≥ 3 or CTCAE ≥ 3). On multivariate analysis, severe postoperative complications were associated with parametrial involvement, preoperative brachytherapy and inclusion in low surgical skills center. Conclusions This study based on prospective data showed that RH has low severe postoperative complications. The main complications were urinary infections and lower limb lymphedema. Patients with early-stage cervical cancer should be referred to expert center to ensure best surgical outcomes.

Objective : To evaluate operative outcomes of hysterectomy +/- adnexectomy by Trans-vaginal Natural Orifice Endoscopic Surgery (vNOTES) in a case series of 33 patients. Study Design : It was a prospective case series study carried out in Darent Valley and Benenden Hospital, to our knowledge, the first units in the United Kingdom to have undertaken VNOTE Hysterectomy. We collected data on a private shared drive noting patient demographics, indications for surgery, operation outcomes and patient follow-up details. Results and Conclusions : Between January and December 2018, 33 patients underwent surgery between two units. Indications for surgery included dysfunctional uterine bleeding, endometrial hyperplasia, pelvic pain, post-menopausal bleeding, prophylactic surgery in BRCA positive patients and one grade 1 stage 1 endometrial cancer in whom laparoscopic hysterectomy was technically difficult and complicated by previous midline laparotomy. Ages ranged from 35 to 75 and BMI from 20-53. Mean operation time was 68.5 min and mean blood loss intraoperatively was 269mls. 15.2% (n = 5) had a blood loss equal or more than 500 mls. There were no intraoperative complications and no conversions to open surgery. The median visual analogue pain score at 6 h post operatively and at discharge was 0. All patients received regular Paracetamol and Ibuprofen and opiate based analgesics were only used on an as required basis. Postoperative complication which included failed trial without catheter, urinary tract infection and urinary dysfunction were reported by four women (12.4%). Only 2 patients re-presented to hospital over a 30-day period and neither required inpatient management. Hysterectomy by vNOTES has advantages over traditional laparoscopic and vaginal hysterectomy that include reduced requirement for intra-abdominal insufflation and head down, absence of trocar related injuries and easier operative access in patients with morbid obesity, or previous abdominal surgery such as midline laparotomy or mesh hernia repair. In addition, both tubes and ovaries can be removed easily due to easier access and visibility and there is no requirement for vaginal descent in order to do so. Plans for a comparative study between laparoscopic hysterectomy and vNOTES hysterectomy are underway.

Objective: To evaluate the best surgical approach for the female urinary incontinence. Methods: Systematic review conducted in MEDLINE® Cochrane, EMBASE and LILACS database up to September 1st, 2017. Articles were selected according to study type, type of intervention and outcomes. Articles were selected by more than one researcher based on title, abstract and full text. The SIGN checklist was used for bias assessment. Results: A total of 165 articles were retrieved from MEDLINE® . Twenty-five studies were elected for full text reading, and 11 of them were selected for the final text analysis. The heterogeneity between questionnaires used in different studies precluded a meta-analysis of results. Conclusion: This study yielded evidences supporting the hypothesis that total and subtotal hysterectomy have different impacts on urinary function of patients with benign uterine diseases. Articles revealed higher frequency of urinary incontinence following subtotal compared to total hysterectomy. RESUMO Objetivo: Avaliar qual a melhor conduta cirúrgica na incontinência urinária feminina. Métodos: Revisão sistemática conduzida no MEDLINE®, Cochrane, EMBASE e LILACS até 1º de setembro de 2017. Os artigos foram escolhidos de acordo com o tipo de estudo e de intervenção, e seus resultados. Os artigos foram selecionados por mais de um pesquisador, com base no título, no resumo e no texto completo. O checklist SIGN foi usado para avaliar vieses. Resultados: No MEDLINE®, foram recuperados 165 artigos. Foram escolhidos 25 estudos para leitura do texto completo, e somente 11 foram escolhidos para análise do texto final. Não foi realizada metanálise dos resultados devido à heterogeneidade dos questionários usados em cada estudo. Conclusão: Encontrou-se evidência que suporta a hipótese de que as histerectomias total e subtotal causam impactos diferentes na função urinária de pacientes com doença uterina benigna. Os artigos mostraram maior frequência de incontinência urinária após histerectomia subtotal quando comparada à total.

Spontaneous coronary artery disease is an uncommon and likely underdiagnosed cause of sudden cardiac death affecting typically young and middle-aged women. We report a case of spontaneous coronary artery disease in the postoperative period in a female patient who developed an acute coronary event after gynecologic surgery. The patient was clinically asymptomatic except for mild hemodynamic instability and ST-segment-elevation myocardial infarction seen on electrocardiogram. Spontaneous coronary artery disease was diagnosed with coronary angiography, and a pharmacological therapy was instituted with favorable results.

To evaluate whether utilization of apical suspension procedures at the time of vaginal hysterectomy for pelvic organ prolapse varies with surgeon specialty.This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. International Classification of Diseases, Ninth Revision, Clinical Modification with a diagnosis of pelvic organ prolapse who underwent vaginal hysterectomy with any combination of pelvic reconstructive procedures. Propensity score matching using available preoperative clinical data was used to ameliorate selection bias by specialty at a ratio of 1 female pelvic reconstructive surgeon (FPMRS) surgeon to 2 obstetrician-gynecologists (OBG). Descriptive statistics were reported as means with standard deviations. Pairwise analysis using Student t test and Fisher exact test was performed where appropriate.After propensity score matching, there were 901 cases performed by FPMRS and 1802 performed by OBG. The overall utilization rate of apical suspension in the matched cohort was 81.7% for FPMRS and 19.8% for OBG (P0.001). Obstetrician-gynecologists were more likely to perform vaginal hysterectomy without apical suspension compared with FPMRS (44.3% vs 5.8%; P0.001) and were also more likely to perform nonapical vaginal repair without also performing an apical suspension, (17.7% vs 9.3%, P0.001), compared to urogynecologists. On multivariable logistic regression, having surgery performed by FPMRS was the only significant variable associated with an increased likelihood of undergoing apical suspension (adjusted odds ratio, 5.34; 95% confidence interval, 4.48-6.36).The FPMRS physicians are more likely to perform apical suspension with vaginal hysterectomy for prolapse repair compared with OBG.

Preoperative counseling about salpingectomy with pelvic surgery is recommended by the American College of Obstetrics and Gynecology for ovarian cancer risk reduction. Our objective was to determine recent practice patterns and patient factors associated with salpingectomy with vaginal hysterectomy (VH) for pelvic organ prolapse (POP) in the USA. We hypothesize that salpingectomy might have become more common in recent years. We queried the 2014–2016 National Surgical Quality Improvement Program database for women with a postoperative diagnosis of POP who underwent VH with any combination of pelvic reconstructive procedures. CPT codes do not differentiate salpingectomy from salpingo-oophorectomy, so subjects were stratified by whether concurrent adnexectomy was performed. Chi-squared and multivariate logistic regression analyses were used to evaluate characteristics associated with adnexectomy. Propensity score matching was utilized when evaluating postoperative complication rates. Of 5,344 women who underwent VH, 2019 (37.8%) had adnexectomy. Adnexectomy rate increased from 34.4% in 2014 to 46.8% in 2016 (p

To report a new surgical technique for hysterectomy using robotic natural orifice transluminal endoscopic surgery (NOTES) as a scarless and gasless procedure. Thirteen consecutive patients with benign uterine disease underwent robotic NOTES hysterectomy at Eulji University Hospital between February 2017 and May 2018. Due to the presence of pelvic adhesions, one of these patients underwent hybrid robotic NOTES hysterectomy with the assistance of isobaric single port laparoscopy; however, there was no conversion to another hysterectomy type such as conventional laparoscopy, laparotomy, or traditional multiport robotic surgery. Median uterine weight was 290 g (range 115–892 g). Median docking and console times were 15 min (range 5–25 min) and 135 min (range 92–215 min), respectively. Mean change in hemoglobin on the first postoperative day was 0.67 ± 0.7 g/dL. Median EBL was 50 mL (20–450 mL). Median postoperative hospital stay was 3 days (3–4 days). No patients experienced postoperative complications such as damage to adjacent organs, re-operation, or vaginal cuff hematoma. Our findings show that robotic NOTES hysterectomy is a feasible and safe scarless and gasless surgical technique. It is an effective, minimally invasive vaginal access alternate to NOTES-assisted vaginal hysterectomy or conventional robotic laparoendoscopic single-site surgery hysterectomy in the surgical management of benign uterine disease. Nevertheless, further prospective controlled studies are needed to determine its full clinical application.

INTRODUCTION AND HYPOTHESIS: Uterine prolapse is a common diagnosis. Today no consensus exists on which operation technique is ideal to treat apical prolapse. Vaginal hysterectomy (VH) with suspension of the vaginal cuff is the most frequently used. The popularity of uterus-preserving techniques is increasing. The aim of this study was to compare the efficiency of vaginal native tissue operations to treat primary apical prolapse, evaluated on risk of relapse surgery.METHODS: Data were obtained from the Danish National Patient Registry (NPR), which contains all operations performed in Denmark. Patients operated on for primary apical prolapse in Denmark 2010-2016 were included and followed until 2017. Clinical data were obtained from the Danish Urogynecological Database. Patients who were previously hysterectomized or operated on for prolapse in the apical compartment were excluded. Data were analyzed using Cox proportional hazard regression analysis and adjusted for age, BMI, smoking, preoperative prolapse stage and previous POP operations.RESULTS: In total, 7247 operations were included. The hazard ratio (HR) for relapse operation in the apical compartment was significantly higher after sacrospinous hysteropexy (SH) compared with the Manchester-Fothergill procedure (MP) [40.2 confidence interval (CI) 21.6-74.7] and VH (8.5 CI: 6.0-12.1). Likewise, the HR was higher in the anterior compartment after SH compared with MP (4.3 CI: 2.9-6.4) and VH (2.8 CI: 2.0-4.0). No convincing difference was found in the posterior compartment. The 5-year reoperation rates were 30%, 7% and 11% after SH, MP, and VH, respectively.CONCLUSIONS: Sacrospinous hysteropexy has exceedingly high numbers of reoperations due to prolapse recurrence.

Objective(s) Most surgeons recommend restriction of activities after minimally invasive gynecologic and pelvic reconstructive surgery. The goal of this study was to identify and assess the postoperative guidelines gynecologists and urogynecologists provide their patients. Methods This was a cross-sectional study of physicians at a national gynecology conference in March 2018. Respondents were asked to answer questions about the typical postoperative recommendations they provide patients after gynecologic surgery as well as their postoperative prescribing habits. Results There were 418 attendees, and 135 (32%) eligible physicians completed the survey. Of respondents, 87% were specialists in female pelvic medicine and reconstructive surgery. Most respondents (61%) were in academic practice. Most respondents (82%-86%) recommended specific postoperative lifting restrictions, and 49% to 52% recommended limiting lifting to a maximum of 10 lb after surgery with some variation depending on the surgical procedure performed. Many respondents (42%-56% depending on the surgical procedure) recommended that patients wait at least 2 weeks before returning to sedentary work. Male respondents and those who were in practice for more than 10 years recommended that patients return to work sooner compared with those who were in practice less than 10 years. Male respondents prescribed fewer opioids to patients after vaginal hysterectomy (P = 0.04) and vaginal prolapse repair (P = 0.03) compared with female respondents. Conclusions After minimally invasive gynecologic or pelvic reconstructive surgery, providers recommend a wide range of postoperative restrictions and prescribe significantly different quantities of opioids during the postoperative period. This study highlights some of the recommendations with the greatest variability.

Objective To explore current practice and influencing factors on adoption of the opportunistic salpingectomy (OS), particularly regarding the decision making, to eventually enhance the development and implementation of clear guidelines. Methods This nationwide cross-sectional survey study was conducted in all hospitals in the Netherlands. An anonymous online survey was sent to gynecologists with special interest in gynecological oncology, gynecological endoscopy or urogynecology and all Dutch gynecology trainees. The survey mainly focused on current practice regarding OS and identification of influencing factors on the level of innovation, organization, healthcare professional and individual patient. Results The response rate was 348 out of 597 gynecologists (58.3%) and 142 out of 340 trainees (41.8%). Current practice of discussing and performing the OS varied widely, with ovarian cancer (OC) risk reduction as most important supportive factor on innovation level. Supportive factors on the level of organization and healthcare provider were; working in a non-training hospital, knowledge of current literature and extensive work experience (in years and annual number of hysterectomies). On individual patient level, a vaginal approach of hysterectomy, negative family history for OC and the presence of firm adhesions were suppressive factors for the OS. Conclusion In this study we evaluated the current practice regarding the opportunistic salpingectomy in the Netherlands and identified influencing factors on different levels to raise awareness and attribute to development of a targeted implementation strategy, on both national and international level.

The treatment of pelvic organ prolapse (POP) in elderly women can be challenging. The vaginal operation known as colpocleisis, the total occlusion of the urogenital hiatus, with concomitant hysterectomy was described by Rouhier and represents a safe, time-saving, and reproducible procedure in the case of POP associated with uterine pathological conditions. It is suitable for elderly women who do not require preservation of coital function. The objective of this video is to provide anatomical illustrations and a precise description of the surgical steps.We present the case of a 62-year-old woman who was referred for hysterectomy in the context of metastatic endometrial cancer. She complained about vaginal bulge and was diagnosed with a POP-Q stage 4 genital prolapse on physical examination. Due to important comorbidities such as arterial hypertension, obesity, and three-site metastatic disease, we suggested a colpocleisis with concomitant vaginal hysterectomy. This approach was intended to treat the prolapse and perform a palliative surgery to alleviate abnormal uterine bleeding.This video illustrates the different surgical steps of a colpohysterectomy according to Rouhier. No intraoperative complications occurred and the postoperative follow-up was uneventful. The patient was fully satisfied and POP has not recurred after a 17-month follow-up.Colpocleisis should remain an exceptional approach, but could be offered to sexually inactive women of advanced age after thorough discussion and patient consent. If a hysterectomy is necessary, Rouhier's operation offers a time-saving, reproducible, and efficient option for women with symptomatic POP who do not desire future vaginal intercourse.

Study Objective Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension. Design Stepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage. Setting An academic tertiary referral center. The ethics committee ruled that approval was not required for this study. Patients A 53-year-old woman. Interventions vNOTES hysterectomy and apical suspension to the uterosacral ligament. Measurements and Main Results A 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA). Conclusion vNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.

Study Objective To determine the safety and feasibility of same-day discharge (SDD) in patients undergoing vaginal hysterectomy with pelvic floor reconstruction. Design Prospective cohort pilot study. Setting Single academic medical center. Patients Women undergoing vaginal hysterectomy with pelvic floor reconstruction were considered for inclusion in the study. Interventions SDD or overnight hospitalization after surgery. Measurements and Main Results A total cohort of 55 women undergoing vaginal hysterectomy and pelvic floor reconstruction for pelvic organ prolapse and/or urinary incontinence was identified. The control group consisted of 19 women who were planned for overnight hospitalization. The intervention group had 36 women who were planned for SDD. In the intervention group 63.9% of patients (n = 23) were successfully discharged home and 36.1% (n = 13) required an unplanned overnight admission. Reasons for unplanned admission included persistent anesthetic effects (dizziness/nausea/drowsiness, n = 9, 69%), uncontrolled pain (n = 1, 7.7%), fever (n = 1, 7.7%), anemia (n = 2, 15.4%), with return to operating room for hematoma evacuation (n = 1, 7.7%). A voiding trial was passed on the first attempt in 30 patients (54.5%). The percentage of successful voiding trials on the first attempt was 30.8% for patients requiring unplanned admission and 78.9% for patients with planned overnight hospitalization (p = .011). There were no significant differences in the number of emergency department visits (p = .677) or unplanned office visits (p = .193) between the control and intervention groups. Conclusion SDD after vaginal hysterectomy with pelvic floor reconstruction appears to be safe and feasible. Patients who were discharged the same day did not require a higher volume of emergency department or office evaluations.

Although the selection of an approach to minimally invasive hysterectomy is relatively straightforward in an ideal patient scenario, it is more difficult in patients who pose operative challenges such as high body mass index (BMI) and enlarged uteri. The objective of this study was to explore the association between surgical approach and operative morbidity after minimally invasive hysterectomy and examine whether the association varies based on patient BMI and uterine size.Retrospective cohort (Canadian Task Force classification II-2).Data abstracted from the American College of Surgeons National Safety and Quality Improvement Project registry.Thirty-six thousand seven hundred fifty-seven women undergoing vaginal, laparoscopic-assisted vaginal, or total laparoscopic hysterectomy for benign indications between January 2005 and December 2012.Associations between surgical approach, BMI, and operative morbidity were examined, stratifying by uterine size (or250 g) and adjusting for covariates. Adjusted means, rate ratios, or odds ratios with 95% confidence intervals (CI) were calculated using linear, Poisson, or logistic regression.Operative times were shortest in women undergoing vaginal hysterectomy regardless of BMI or uterine size (all p .02). Although operative time increased with BMI, the association varied with uterine size in women undergoing vaginal hysterectomy; increasing BMI had a minimal impact on operative time with small uteri250 g but lengthened operative time in uteri250 g. Compared with vaginal hysterectomy, total laparoscopic hysterectomy had lower odds of blood transfusion (all p .02) and shorter hospitalizations (all p .03) regardless of uterine size or BMI. Stratifying by uterine size, the association was strongest in morbidly obese women with small uteri; women with uteri250 g and BMI40 kg/mMajor operative morbidity after minimally invasive hysterectomy is rare regardless of the surgical approach. A vaginal approach to hysterectomy is associated with the shortest operative times, but increasing BMI results in a rapid escalation of operative time in women with large uteri. Total laparoscopic hysterectomy is associated with shorter hospitalizations and lower odds of blood transfusion across the BMI spectrum, particularly in women with small uteri. Laparoscopic-assisted vaginal hysterectomy appears to confer no specific advantage over the vaginal or laparoscopic approaches.

ObjectiveThe aim of this study was to compare intraoperative and short-term postoperative outcomes and recurrence of laparoscopically assisted radical vaginal hysterectomy (LARVH) to abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer.MethodsA search of PubMed, EMBASE, and Cochrane library search trial (central) databases was conducted from database inception through December 2015. We included studies comparing surgical approaches with radical hysterectomy (LARVH vs ARH) in women with stages IA1 to IIB cervical cancer. Outcomes included blood loss, operative time, number of lymph nodes retrieved, intraoperative complications, hospital stay, and prognosis.ResultSeven studies were included (4 prospective cohort studies and 3 case control studies) enrolling 794 women; 349 women were treated by LARVH, and 445 were treated by ARH. Laparoscopically assisted radical vaginal hysterectomy was associated with less blood loss (weight mean difference [WMD], −237.45; 95% confidence interval [CI], −453.42 to −21.47), wound-related complications (odds ratio, 0.17; 95% CI, 0.05–0.61), shorter hospital stay (WMD, −2.01; 95% CI, −2.52 to −1.51), and longer operative time (WMD, 48.95; 95% CI, 42.08 to 55.82) versus ARH. Laparoscopically assisted radical vaginal hysterectomy was comparable with ARH in number of lymph nodes retrieved, urinary-related complications, rectal injury, lymphedema, and all prognosis indicators.ConclusionsThe evidence suggests that LARVH is superior to ARH with lower blood loss, less wound-related complications, and shorter hospital stay. Laparoscopically assisted radical vaginal hysterectomy and ARH seem equivalent in number of lymph nodes retrieved, urinary-related complications, rectal injury, lymphedema, and prognosis.

To compare the effects of the laparoscopic approach versus the vaginal route for the management of vaginal cuff closure during total laparoscopic hysterectomy on female sexual function in premenopausal patients with benign gynecologic conditions.A prospective study with a randomized, double-blind design (Canadian Task Force Classification I).A university hospital.Patients who were scheduled to have total laparoscopic hysterectomy because of benign conditions.Patients were randomized to vaginal cuff closure via the vaginal route versus the laparoscopic approach. The study included a total of 70 patients; 34 underwent the laparoscopic approach in the management of vaginal cuff closure, and 36 underwent the vaginal route.Female sexual function and vaginal length were measured. The duration of total surgery was significantly shorter in the laparoscopic approach group compared with the vaginal route group (112.2 ± 36.5 vs 122.7 ± 53.6, p.05). The total Female Sexual Function Index scores preoperatively and 3 months postoperatively were similar between the laparoscopic approach and vaginal route groups (all p.05). Vaginal lengths 3 months postoperatively were significantly longer in the laparoscopic approach group compared with the vaginal route group (8.39 ± 0.90 vs 7.34 ± 1.17, p.05). The duration of cuff closure was significantly shorter in the vaginal route group compared with the laparoscopic approach group (8.92 ± 2.23 vs 7.51 ± 2.5, p.05). Preoperative vaginal lengths were significantly longer in comparison with 3 months postoperatively both in the laparoscopic approach and the vaginal route groups (all p.05). The preoperative total Female Sexual Function Index scores were significantly higher in comparison with 3 months postoperatively both in the laparoscopic approach and the vaginal route groups (all p.05).The results of this study indicate that the laparoscopic approach for vaginal cuff closure might be preferable because of better postoperative vaginal length and a shorter duration of total surgery time.

To describe a simple and efficient technique for suturing the vaginal cuff in robotic-assisted single-site hysterectomy using barbed suture and a straight needle. Consecutive patients undergoing robotic-assisted single-site hysterectomy from February 2014 to August 2015 at Dong San Hospital, Keimyung University were included. Surgeons used two barbed sutures in a running fashion to close the vaginal cuff. A barbed suture was exclusively used with a straightened needle in upward direction from posterior vaginal cuff to anterior vaginal cuff which played a pivotal role for closure. A total of 100 patients underwent robotic-assisted single-site hysterectomy. The total operation time was 132.5 min and vaginal cuff closure time was 12.0 min. There were no postoperative complications; vaginal cuff dehiscence, vaginal cuff infection, and vaginal bleeding that require surgical intervention or admission. The use of barbed suture with straightened needle to close the vaginal cuff in robotic-assisted single-site hysterectomy is easy to perform and demonstrates safety and efficacy. This technique offers secure, fast, and effective incision closure.

Background and Aims: This controlled trial with II-1 evidence compared the safety and efficacy of the new laparoscopic-assisted combined hysterectomy (LACH) with the standard surgical technique laparoscopic-assisted vaginal hysterectomy (LAVH) in general and in patients displaying risk factors (large uterus, vaginal nulliparity, prior caesarean section). Methods: From June 2007 to September 2008, 101 patients underwent a hysterectomy at the Clinic of Gynaecology, Obstetrics and Gynaecological Oncology at the Pius Hospital, University Hospital for Gynaecology in Oldenburg. The main outcome measures were feasibility, postoperative analgesia, postoperative inflammatory reaction, and duration of surgery. Statistical analyses were performed using SPSS for Windows (p < 0.05). Results: We observed no significant differences between LACH and LAVH regarding outcome parameters or when risk factors were considered. Within the LACH group, the duration of surgery was significantly shorter for patients with UW Conclusion: In terms of technical feasibility, LACH represents a safe alternative for abdominal HE when LAVH is contraindicated.

Objective To evaluate the safety and feasibility of gasless transumbilical single-port laparoscopic-assisted vaginal hysterectomy (LAVH) for the management of large uteri weighing 500 g or more. Study design We conducted a retrospective comparative study of women with large uteri, each undergoing gasless multi-port or single-port LAVH. Preoperatively, gonadotropin-releasing hormone agonist was administered and autologous blood was donated except for cases requiring immediate surgery. Additionally, intraoperative blood salvage and donation was performed in select cases. In single-port LAVH, a wound retractor was used to make a working port through umbilical incision. After the surgical view was secured using an abdominal wall-lift device, the surgical procedures were performed using conventional laparoscopic instruments. In select cases, temporary endovascular occlusion of the bilateral internal iliac arteries was performed to reduce intraoperative hemorrhaging. Results Of the 650 women managed by multi-port or single-port LAVH, 55 and 67 women each with uteri weighing 500 g or more, respectively, were included. In single-port LAVH group, the median age was 47 years. Twelve women were nulliparous and 3 women with 2 cesarean deliveries each, had never had a vaginal delivery. The most frequent surgical indication was uterine myoma. In the single-port LAVH group, the surgical procedures included LAVH alone ( n = 36), LAVH and bilateral salpingo-oophorectomy ( n = 22), LAVH and unilateral salpingo-oophorectomy ( n = 8), and LAVH and appendectomy ( n = 1). Extensive adhesiolysis was required in eight cases. The median extirpated tissue weight was 652 g with a median estimated intraoperative blood loss of 450 mL. A significant positive linear correlation was observed between the operative time or estimated blood loss and the extirpated uterine weigh. Although excessive bleeding exceeding 1000 mL was noted in 15 cases, a transfusion of bank blood was not required by using preoperatively donated autologous blood and intraoperative autologous blood salvage and donation. Extended hospitalization was required in six cases. The median surgical duration in the single-port LAVH group was significantly longer than that in the multi-port LAVH group. Conclusion Gasless single-port LAVH is a feasible alternative that can yield similar major surgical outcomes as multi-port LAVH, with potential cosmetic benefit.

Introduction and hypothesis Surgical management of uterine prolapse varies greatly and recently uterus-preserving techniques have been gaining popularity. The aim of this study was to compare patient-reported outcomes after cervical amputation versus vaginal hysterectomy, with or without concomitant anterior colporrhaphy, in women suffering from pelvic organ prolapse. Method We carried out a population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. Between 2006 and 2013, a total of 3,174 patients with uterine prolapse were identified, who had undergone primary surgery with either cervical amputation or vaginal hysterectomy, with or without concomitant anterior colporrhaphy. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed, in addition to complications and adverse events. Between-group comparisons were performed using univariate and multivariate logistic regression. Results There were no differences between the two groups in neither symptom relief nor patient satisfaction. In both groups a total of 81 % of the women reported the absence of vaginal bulging 1 year after surgery and a total of 89 % were satisfied with the result of the operation. The vaginal hysterectomy group had a higher rate of severe complications than the cervical amputation group, 1.9 % vs 0.2 % (p

The best predictors for postoperative anatomic apical success after transvaginal uterosacral ligament suspension remain unknown. The aim of this study was to determine if there is a correlation between the preoperative D point and anatomic outcomes for apical prolapse after 1 year.This retrospective cohort study included subjects undergoing transvaginal uterosacral ligament suspension from 2008 through 2013 who had at least 1 year follow-up. Demographic information, preoperative and postoperative Pelvic Organ Prolapse Quantification (POPQ) examination measurements, need for retreatment or repeat surgery, and assessment of pelvic floor symptoms were reviewed. Postoperative apical success was defined as C point descent no more than one third into the vaginal canal.One hundred twenty-five women met inclusion criteria and had follow-up at 1 year or more. Concomitant procedures included anterior/posterior repair and midurethral sling. Mean follow-up time was 22.8 months (range, 12-63 months). At last follow-up, 96% met criteria for apical success. A more negative preoperative D point was significantly related to improved postoperative apical support, with each 1-cm descent in preoperative D point resulting in a postoperative C point that was 0.21 cm lower (P = 0.0005). Based on the receiver operating characteristic curve, a "cutoff" D point value of -4.25 (sensitivity, 0.8; specificity, 0.65) was determined to be a predictor of postoperative apical success at 1 year or more.The preoperative D point correlates with postoperative apical support, and a clinically meaningful relationship exists between the preoperative D point and anatomic apical success.

Study Objective To determine the safety of manual vaginal morcellation by evaluating the rates of incidental uterine malignancy and manual vaginal morcellation after vaginal or laparoscopic-assisted vaginal hysterectomy. Design Retrospective analysis (Canadian Task Force classification II-2). Setting University of Texas Southwestern Medical Center, Dallas, TX. Patients Women (n = 1,629) undergoing vaginal or laparoscopic-assisted vaginal hysterectomy. Interventions Vaginal hysterectomy (n = 1,091) or laparoscopic-assisted vaginal hysterectomy (n = 538) with and without scalpel morcellation. Measurements and Main Results The number of uterine malignancies, rate of vaginal morcellation, surgical indications, pathology diagnoses, and uterine weights were evaluated. Chi-square analysis was used to compare categoric data, and analysis of variance was used to compare uterine weights. There were no cases of leiomyosarcomas. There were 2 other sarcomas, 4 smooth muscle tumors of uncertain malignant potential, and 8 endometrial adenocarcinomas. The vaginal morcellation rate was 19.4%, but no malignancy was morcellated. Myomas were more common preoperatively and histologically in morcellated specimens. Mean (± standard deviation) uterine weights for morcellated versus nonmorcellated laparoscopic-assisted vaginal hysterectomy specimens were 285.5 ± 159.3 versus 140.1 ± 83.6 g (p Conclusion Vaginal manual morcellation is safe with a low risk of incidental malignancy. Variables that influence the decision for the vaginal approach may also affect malignancy risk and morcellation decisions. Thus, all patients undergoing vaginal or laparoscopic-assisted vaginal hysterectomy should be counseled regarding incidental malignancy, risk of morcellation, and alternatives for intact specimen removal.

Uterosacral ligament suspension at the time of primary prolapse repair represents a well-established surgical option. Our aim was to compare the effectiveness, complications rate, and functional results of modified McCall culdoplasty and Shull suspension. Patients who underwent vaginal hysterectomy and cuff suspension for pelvic organ prolapse were retrospectively analyzed. McCall culdoplasty (group A) or Shull suspension (group B) were performed according to surgeon choice based on age and sexual activity. Perioperative data, objective, and subjective cure rate were noted. A total of 339 patients (215 in group A and 124 in group B) completed follow-up. Operating time and blood loss were slightly higher in group B. The complications rate was similar in the two groups. Anatomical outcomes in terms of recurrence and reoperation rate did not show any statistically significant differences. POP-Q items analysis revealed only a different total vaginal length between groups (8 mm longer in group B). Functional outcomes were similar in the two groups as was patient satisfaction. Both uterosacral ligament suspension procedures were shown to be safe and effective. There were no clinically significant differences with regard to surgical data, complications, anatomical, functional, and subjective outcomes between modified McCall culdoplasty and Shull suspension.

It has long been held as conventional wisdom that urogenital fistulae in low-income and middle-income countries are almost exclusively of obstetric aetiology, related to prolonged neglected obstructed labour, whereas those seen in high-income countries are largely iatrogenic in nature. There is, however, a growing perception amongst those working in the field that an increasing proportion of urogenital fistulae in low-income and middle-income countries may be iatrogenic, resulting from caesarean section. Recent studies suggest that adverse patterns of care may also be emerging in high-income countries; an increase in the risk of both vesicovaginal and ureterovaginal fistulae following hysterectomy has been reported, concurrently with the reduction in overall use of the procedure. These apparent secular trends are discussed in the context of evolution of practice, teaching and training in obstetrics and gynaecology.

The aim of this prospective observational study was to obtain a better understanding of the anatomy and to classify the observed different perineal presentations at the time of posterior colporrhaphy and to describe specific surgical techniques used.To classify the observed perineal findings, the Pelvic Organ Prolapse Quantification System with a newly introduced additional measurement of the perineal ridge (PR) was taken intraoperatively and postoperatively in 121 consecutive women undergoing posterior colporrhaphy. Dependent on the preoperative classification of the perineum as being normal (type 1), deficient (type 2), or with a PR (type 3), a specific surgical repair was performed for each type of perineal presentation.The perineal presentations were categorized into 3 defined groups. Type 1 (normal perineum) was seen in 40%, type 2 (deficient perineum) in 13%, and type 3 (PR) in 47%. A type 1 correlates with prior cesarean section (P = 0.29), a type 2 correlates with prior vaginal delivery (P = 0.05), and type 3 perineum with prior pelvic floor surgery (P0.0001). When perineal type-specific surgical techniques were performed, the perineal body length increased postoperatively in type 2 (P0.05), decreased in type 3 (P0.05), and remained unchanged in those with type 1 defects.This study demonstrates that the perineal region can be clearly defined into 3 categories. The distinct perineal presentation correlates with the previous gynecological history. With a specific perineal repair at the time of posterior colporrhaphy, the perineal anatomy can be restored in the short term.