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Minimally invasive surgery on treatment of early-stage cervical cancer is debatable. Traditional approaches of colpotomy are considered responsible for an inferior oncological outcome. Evidence on whether protective colpotomy could optimize minimally invasive technique and improve prognoses of women with early-stage cervical cancer remains limited. We produced a systematic review and meta-analysis to compare oncological outcomes of the patients treated by minimally invasive radical hysterectomy with protective colpotomy to those treated by open surgery according to existing literature. We explored PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to December 2022. Inclusion criteria were: (1) randomized controlled trials or observational studies published in English, (2) studies comparing minimally invasive radical hysterectomy with protective colpotomy to abdominal radical hysterectomy in early-stage cervical cancer, and (3) studies comparing survival outcomes. Two reviewers performed the screening, data extraction, and quality assessment independently. A total of 8 retrospective cohort studies with 2020 women were included in the study, 821 of whom were in the minimally invasive surgery group, and 1199 of whom were in the open surgery group. The recurrence-free survival and overall survival in the minimally invasive surgery group were both similar to that in the open surgery group (pooled hazard ratio, 0.88 and 0.78, respectively; 95% confidence interval, 0.56-1.38 and 0.42-1.44, respectively). Minimally invasive radical hysterectomy with protective colpotomy on treatment of early-stage cervical cancer had similar recurrence-free survival and overall survival compared to abdominal radical hysterectomy. Protective colpotomy could be a guaranteed approach to modifying minimally invasive technique., Competing Interests: Declaration of competing interest The authors declare no competing interest., (© 2024 Published by Elsevier Ltd.)

Introduction and Hypothesis: The Variation in Surgical Technique study (VaST), demonstrated the large variation in surgical techniques used in native tissue (NT) anterior pelvic organ prolapse (POP) repairs. However, there are few comparative studies of different surgical techniques. This study was aimed at exploring whether surgical technique influenced the outcomes of NT anterior POP repairs., Methods: The surgical techniques of 22 consultant surgeons performing NT anterior POP repairs were filmed and categorised. These surgeons performed 809 anterior repairs within the PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trial (PROSPECT). Logistical regression models were used to determine the influence of the different surgical techniques on subjective and objective outcomes, using data collected during PROSPECT., Results: In adjusted multivariate linear regression models, fascial-flap repair was associated with an improved subjective outcome (POP-SS) compared with midline plication (β = -2.50 [-4.42 to -0.57]; p = 0.01). At 12 months, separate fascial defect repair was associated with a poorer objective outcome than midline plication (OR 6.06 [1.82-3.52], p = 0.006). At 24 months, deep dissection was associated with a poorer POP-SS than superficial dissection (0.32-2.60, p = 0.0). Continuous-locking closure of the skin was also associated with improved POP-SS compared with continuous non-locking closure (12 months: β = -1.94 [-3.42 to -0.45], p = 0.01)., Conclusion: Surgical technique may influence the outcome of native tissue anterior POP repairs. Our results should not change practice but inform future research; to develop methods of explicitly recording surgical techniques and allow confirmation of the effect of these aspects of technique on outcome., (© 2023. The Author(s).)

Background and Objectives: This is a prospective trial of the endo-stapler application for vaginal closure before colpotomy in cases of carcinoma endometrium and carcinoma cervix, managed by minimally invasive surgery with due consideration of its surgical technique and short-term oncologic follow-up outcomes., Methods: This was a prospective, single center study completed between March 1, 2020 and December 31, 2022. A total of 62 patients (43 cases of carcinoma endometrium and 19 cases of carcinoma cervix) were recruited for the study. Oncologic survival outcomes at the end of 1 and 2 years were documented., Results: There were no major intraoperative bowel, urinary, or vascular injuries. None of the cases required conversion to laparotomy peroperatively. Our study had 8 patients with carcinoma endometrium (8/43) and 7 patients of carcinoma cervix (7/19) who have completed 24 months of follow-up without any recurrence to date., Conclusion: Endo-stapler application for enclosed colpotomy to prevent tumor spillage is a futuristic step in gynecologic oncology cases managed by laparoscopy., Competing Interests: Conflict of interests: none., (© 2023 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Introduction and Hypothesis: We aimed to compare perioperative complications for women who underwent colpocleisis with and without concomitant hysterectomy, and report the rate of concomitant hysterectomy., Methods: We conducted a retrospective study using the Healthcare Cost and Utilization Project (HCUP) - Nationwide Inpatient Sample 2004 to 2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify women with pelvic organ prolapse (POP) who underwent colpocleisis with or without concomitant hysterectomy. Trend over time of each procedure type was created. We calculated odds ratios (ORs) to determine the risk of perioperative complications with or without concomitant hysterectomy. ORs were adjusted for age, race, income, insurance plan, and hypertension., Results: Of 253,100 adult women who underwent POP repair, 7,431 had colpocleisis. Colpocleisis with concomitant hysterectomy was performed in 1,656 (22.2%) and 5,775 (77.7%) underwent colpocleisis alone (2,469 [33.2%] had a previous hysterectomy). Hysterectomy rates among women with POP undergoing colpocleisis remained relatively steady, whereas those undergoing colpocleisis without hysterectomy declined over time. Prevalence of any complications was higher among those with concomitant hysterectomy (11.4% vs 9.5%, p=0.023). Adjusted OR showed that concomitant hysterectomy increased the risk of complications (OR 1.93, 95% CI 1.45-2.57, p<0.001)., Conclusions: Our large administrative data analysis suggests an increased risk of complications when performing a hysterectomy at the time of colpocleisis. A concomitant hysterectomy was performed in 22% of cases. Whether or not to include hysterectomy at the time of colpocleisis is based on shared decision making, influenced by individual patients' values, comorbidities, and risk of complications., (© 2023. The International Urogynecological Association.)

Abstract: This study compared survival outcomes for patients with stage IB1 to IIA2 (International Federation of Gynecology and Obstetrics stage 2009) cervical cancer who underwent open radical hysterectomy (ORH) versus those who underwent minimally invasive radical hysterectomy (MIRH) using vaginal colpotomy (VC).Data for 550 patients who were diagnosed with cervical cancer at our institution during the period August 2005 to September 2018 was retrospectively reviewed. Of these, 116 patients who underwent radical hysterectomy (RH) were selected after applying the exclusion criteria. All MIRH patients underwent VC. Clinicopathological characteristics and survival outcomes between the ORH and MIRH groups were compared using appropriate statistical testing.Ninety one patients were treated with ORH and 25 with MIRH during the study period. Among the MIRH patients, 18 underwent laparoscopy-assisted radical vaginal hysterectomy and 7 underwent laparoscopic RH. Preoperative conization was performed more frequently in MIRH patients than in ORH patients (44% vs 22%, respectively, P = .028). The incidence of lymph node invasion was higher in the ORH group than in MIRH group (37.4% vs 12.0% respectively; P = .016). Following RH, ORH patients underwent adjuvant treatment more frequently than MIRH patients (71.4% vs 56.0%, respectively, P = .002). There were no significant differences between ORH and MIRH patients for either progression-free survival (PFS) (91.3% vs 78.7%, respectively; P = .220) or 5-year overall survival (OS) (96.6% vs 94.7%, respectively, P = .929). In univariate analysis, lympho-vascular space invasion was the only clinicopathological feature associated with decreased PFS. No other clinicopathological factors was significantly associated with PFS or OS in univariate and multivariate analyses.Despite a higher incidence of unfavorable prognostic factors in ORH patients, their survival outcomes were not different to those of MIRH patients with VC., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created., Methods: Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS., Results: 30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95])., Conclusion: DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival., (© 2021. The Author(s).)

Abstract: This study aimed to know the distance of the cervicovaginal junction (CVJ) to the anterior peritoneal reflection (APR) as measured in surgical specimens, and assess the distance between the CVJ and APR to ensure safe anterior colpotomy for vaginal hysterectomy among Korean women.Patients who underwent vaginal hysterectomy were included in the analysis. According to the presence of pelvic organ prolapse or menopausal status, the distance from the CVJ to the APR was assessed preoperatively through transvaginal ultrasonography (TV-US), as well as intraoperatively using surgical specimens. The intraclass correlation coefficient was used to determine the reliability between 2 measurements.In total, 171 patients were included. The median distance from the CVJ to the APR measured on TV-US was 19.8 (3.3-41.3) mm. Meanwhile, the median distance from the CVJ to the APR measured using the surgical specimen was 26.0 (12.0-55.0) mm. The intraclass correlation coefficient for the absolute agreement between 2 measurements was 0.353 (95% confidence interval: 0.002-0.570; P < .001), which is indicative of poor reliability. The median distance from the CVJ to the APR measured using the surgical specimen did not differ significantly between the 2 groups according to pelvic organ prolapse (26.0 [12.0-55.0] vs 27.5 [17.0-55.0] mm, P = .076] and menopausal status (27.0 [15.0-55.0] vs 26.0 [12.0-55.0] mm, P = .237).TV-US does not an accurately measure the dissection plane length from the CVJ to the APR during anterior colpotomy. During vaginal hysterectomy, the median distance from the CVJ to the APR measured using the surgical specimen was 26 (12.0-55.0) mm, which can help decrease surgical complications., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives: The aim of this study was to define new techniques for performing vaginal closure with endo-staplers to prevent tumor spillage during laparoscopic surgeries for endometrial cancer and early stage cervical cancer., Methods: Thirteen patients were retrospectively studied for the use of endo-staplers for vaginal closure before colpotomy during laparoscopic surgeries for endometrial cancer and early stage cervical cancer to prevent tumor spillage., Results: There were no short-term or any long-term complication related to the use of the endo-staplers for colpotomy in the surgeries included in this study., Conclusion: Use of the endo-staplers to close the vagina before colpotomy according to the technique described is safe and feasible, with prevention of gross spillage of any malignant cells in the peritoneal cavity or vagina, which will further have a favorable oncologic outcome., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Study Objective: Morcellation is a technique to remove large specimens by means of small incisions and is commonly used in gynecologic procedures [1]. In this video, we demonstrate contained manual morcellation techniques in benign gynecologic surgeries., Design: Stepwise demonstration of 4 techniques with narrated video footage., Setting: Tertiary academic teaching hospital., Interventions: This video showcases 4 contained manual morcellation techniques: abdominal extraction through an umbilical "mini-laparotomy" incision, abdominal extraction through a suprapubic "mini-laparotomy" incision, transvaginal extraction through the colpotomy, and transvaginal extraction through the posterior cul-de-sac with the uterus in place. A particular strategy should be selected on the basis of appropriate patient characteristics and surgical factors [2]., Conclusion: Minimizing risk during tissue extraction is critical to minimally invasive procedures. The morcellation techniques displayed in this video allow for tissue extraction through small incisions while reducing the risk of spreading an undiagnosed malignancy., (Published by Elsevier Inc.)

Objective: To demonstrate the feasibility of a protective maneuver to avoid tumor exposure during laparoscopic radical hysterectomy., Design: This video illustrates the vaginal cuff closure technique in cervical cancer surgery., Setting: The Oncologic Gynecology Department at the University Hospital La Fe., Interventions: After the Laparoscopic Approach to Cervical Cancer trial [1], the laparoscopic approach to the surgical treatment of cervical cancer has been questioned: laparotomic surgery has been associated with a better cancer outcome. This publication has changed the current approach recommendation for performing radical hysterectomy from minimally invasive surgery to open surgery. There are some theories that might justify these findings. In minimally invasive surgery, the use of a uterine manipulator can condition the spread owing to erosion and friction caused on the tumor, even leading to the perforation of the tumor. In addition, intraperitoneal colpotomy can lead to pelvic peritoneum contamination by the tumor. To close the gap between laparoscopy and laparotomy, some protective maneuvers, such as vaginal cuff closure, have been proposed [2,3]. These strategies aim to reduce the possibility of manipulation or exposure of the tumor to the pelvis during colpotomy in laparoscopic radical hysterectomy. These protective maneuvers have been shown to decrease the relapse rate in retrospective studies [4]. However, prospective trials are needed to elucidate and confirm these findings. In this video, we explain step-by-step the technique of vaginal cuff closure before a radical hysterectomy performance for uterine cervical cancer. First, the nodal status is established by laparoscopic sentinel lymph node dissection and frozen section study. Bilateral pelvic lymphadenectomy is completed according to the size of the tumor. In the case of negative nodal status, the vaginal cuff is closed: Approximately 2 to 3 cm from the tumor (depending on its size), a circumferential incision of the vaginal mucosa is performed, followed by the dissection of the vaginal wall, which should be sufficient to allow a tension-free vaginal closure. The vaginal cuff is then closed with a running suture. A laparoscopic radical hysterectomy is then completed, and the surgical specimen is removed without any manipulation of the tumor., Conclusion: Avoiding manipulation of the tumor during cancer surgery is crucial. A vaginal cuff closure technique appears to be an easy protective maneuver that prevents tumor exposure and manipulation during laparoscopic radical hysterectomy., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Purpose: The effectiveness of vaginectomy compared to that of local tumor excision (LTE) for the International Federation of Gynecology and Obstetrics (FIGO) stage I and II vaginal carcinoma is unclear. We aimed to clarify if the effectiveness of vaginectomy is comparable to that of LTE in the real world., Methods: We retrospectively evaluated data of patients with primary vaginal carcinoma registered in the Surveillance, Epidemiology, and End Results Program (SEER) database from 2004 to 2016. The multivariate Cox proportional hazards models and Fine-Gray competing risk models were used to estimate the overall survival (OS) and disease-specific survival (DSS) after propensity score matching., Results: Of the 533 patients with FIGO stage I and II primary vaginal carcinoma, 243 and 290 patients were treated with vaginectomy and LTE, respectively. Vaginectomy was significantly associated with improved OS [unadjusted hazard ratio (HR) = 0.70, 95% confidence interval (CI) 0.53-0.95, P = 0.020; adjusted HR = 0.63, 95% CI 0.46-0.87, P = 0.005] and DSS [unadjusted subdistribution HR (sHR) = 0.75, 95% CI 0.52-1.07, P = 0.115; adjusted sHR = 0.65, 95% CI 0.44-0.97, P = 0.036]. Age, marital status, histology type, FIGO stage, chemotherapy, and lymph node metastases were significant prognostic factors of survival. Moreover, radiotherapy did not influence the effectiveness of vaginectomy. Subgroup and sensitivity analysis confirmed the consistent beneficial effectiveness of vaginectomy., Conclusion: Compared with LTE, vaginectomy results in significantly prolonged survival in patients with FIGO stage I and II primary vaginal carcinoma. Thus, it can be the preferred treatment for FIGO I and II vaginal cancer regardless of radiotherapy status.

Abdominal cerclage is an effective treatment for cervical incompetence in patients with a previously failed vaginal cerclage or with anatomic restrictions to a vaginal cerclage. Management of second trimester complications that warrant a delivery impose a complex clinical situation in patients with an abdominal cerclage. We report 3 cases of successful removal of an abdominal cerclage by posterior and anterior colpotomy in the second trimester of pregnancy. This new and minimally invasive surgical technique avoids the need for extensive dilation, laparoscopy, or laparotomy to remove the cerclage and allow a vaginal delivery., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Minimally invasive surgery (MIS) for radical hysterectomy (RH) has been reported with inferior oncologic outcomes in the New England Journal of Medicine [1,2]. Some studies have suggested that the no-touch technique may be a useful procedure to prevent tumor spillage and improve survival. Therefore, we performed RH targeting early-stage cervical cancer using the laparoendoscopic single-site (LESS) approach with an enclosed colpotomy and without a uterine manipulator [3]., Design: Video demonstration of the technique., Setting: A hospital., Interventions: A 48-year-old postmenopausal woman received a diagnosis of stage IB1 (International Federation of Gynecology and Obstetrics, 2018) cervical cancer [4]. After being fully informed of the benefits and risks of different surgical approaches (laparotomy and MIS), she consented to the MIS. The type C RH through the LESS approach was performed successfully. The final pathologic findings confirmed stage IB1 cervical carcinoma. The patient recovered quickly, albeit with slight pain, and the incision scar was hidden perfectly for cosmetic purposes., Conclusion: This video demonstrates that LESS-RH with vaginal closure and without a manipulator is feasible and safe. Suspension skills played a significant role in LESS-RH. In addition, this surgical procedure involved 4 specific techniques to prevent tumor spillage: creation of a vaginal cuff, avoidance of a uterine manipulator, standard type C radical hysterectomy, and bagging of the specimen. These adaptations were meant to minimize tumor manipulation and disruption for reducing the increased risk of recurrence. However, further verifications are still required., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Gender-affirming vaginectomy treats gender dysphoria associated with the presence of a vagina in transgender males. 1 , 2 Prior reported approaches include transperineal vaginectomy, mucosal fulguration, and robotic-assisted. We present key steps in transperineal gender-affirming vaginectomy in a 39-year-old transgender male., Methods: Informed consent for video recording was obtained. The patient underwent a first-stage phalloplasty 6 months prior. He was placed in high lithotomy Tredelenberg position. After Foley placement, an incision was made along the mucocutaneous junction laterally and posteriorly. The anterior sulci were incised and a transverse incision made anteriorly at the bladder neck. The vaginal mucosa was excised, except for the distal anterior vaginal wall mucosa which would be mobilized as a flap for urethral lengthening later. The paravaginal space was closed with a series of purse-string sutures starting at the apex. The anterior vaginal wall flap is mobilized with the base of the flap at the urethral meatus. Cystoscopy confirms ureteral patency and no lower urinary tract involvement. A suprapubic tube was placed. The procedure then proceeded with a second-stage phalloplasty that included urethral lengthening and scrotoplasty., Results: The demonstrated procedure took 110 minutes and estimated blood loss was 75 mL. In our published series of 40 vaginectomies for 27 phalloplasties and 13 metoidioplasties, median operative time was 135 minutes and median estimated blood loss was 250cc. 3 No complications related to the vaginectomy, including mucocele, fistulae to the vaginal space, or visceral injuries occurred. Peritoneal entry occurred in 44% of the cases and was closed primarily without further sequelae. Two patients required blood transfusion and 1 patient had C. difficile colitis. The anterior vaginal wall mucosa flap was incorporated in 83% of the time., Conclusion: Transperineal vaginectomy results in low periprocedural complications, takes approximately 2 hours after a learning curve. Detailed results from our series of these procedures have been previously reported. 3 ., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Since the era of neoadjuvant chemotherapy, complications of pelvic organ prolapse (POP) post-radical cystectomy have become more common; however, the exact incidence is not documented in the literature. The objective was to repair post-radical cystectomy POP, despite the lack of endopelvic fascia normally needed for this type of repair., Methods: Three patients aged 60 to 80 had symptomatic POP (of all three compartments: apical, anterior, and posterior) following radical cystectomy and ileal conduit urinary diversion, and no interest in maintaining their coital abilities. Two of the three women were status post-hysterectomy. Colpocleisis, which is known to have a success rate of almost 100%, was performed on the first two patients, with a recurrence of the prolapse shortly after this correction (2-4 months), probably due to the lack of endopelvic fascia. Following the failure of the procedure, a side-to-side closure of the vagina was performed. The latter was the procedure of choice performed on the third patient. We present a video clip of the vaginal closure to demonstrate the procedure performed., Results: Repair was successful in all three cases, with no relapse to date (4 months post-surgery)., Conclusions: Closure of the vaginal canal successfully treated POP in our case series. There were no intra- or postoperative complications in any of the cases. Patients were discharged the following day and did not show any signs of recurrence at follow-up (3, 5, and 6 months post-surgery).

Introduction and Hypothesis: The causes of recurrence of pelvic organ prolapse (POP) are sufficiently understood. However, few studies are available evaluating reoperation for recurrence of POP. This study evaluates the efficacy and safety of LeFort colpocleisis for recurrent POP., Methods: We reviewed data from patients with recurrent POP who underwent LerFort colpocleisis at a center between March 2012 and April 2017. Quality of life was assessed using the Pelvic Floor Distress Inventory Questionnaire (PFDI-20) scores. The Patient Global Impression of Improvement scale (PGI-I) was used to assess self-perceived success and subjective measures of satisfaction. The Clavien-Dindo classification (CD) was used to assess the safety of the procedure. Chi-square and paired t-tests were used to compare the same patients before and after treatment in the follow-up., Results: Twenty-six patients with recurrent POP after previous prolapse surgery underwent LeFort colpocleisis. Most of these patients had at least one comorbidity. The mean age (years) was 71.8 (7.3). The mean time to recurrent POP was 5.602 (3.643) years. There were no intraoperative bladder lesions or rectal lesions. At mean follow-up of 33.1 months, all patients had no recurrence (< stage 2), significant resolution of awareness of prolapse (P < 0.05), and significantly improved satisfaction on PGI-I after surgery. Minor complications were classified as CD II level in four cases (15.4%)., Conclusion: This study suggests that LeFort colpocleisis is feasible and safe for recurrent POP, especially in older women with comorbidities.

Introduction and Hypothesis: The apical compartment is a keystone in POP treatment. Sacrospinous fixation, suggested half a century ago, today is still one of the most popular and efficient methods of colpo-hysteropexy. However, it has specific side effects: chronic pain syndrome, dyspareunia and а high rate of cystocele de novo. We aimed to evaluate the efficacy and safety of unilateral sacrospinous hysteropexy with a synthetic apical sling combined with anterior subfascial colporrhaphy., Methods: Following the suggested technique, 174 women with anterior-apical prolapse underwent surgery. The follow-up period took 12 months. Pre- and postoperative examination included: urogynecological examination (POP-Q), uroflowmetry, ultrasound of the bladder and filling in of validated questionnaires (PFDI-20, PISQ-12)., Results: The mean surgery time was 26 ± 7.84 min. No cases of damage of the bladder or rectum or of intraoperative clinically significant bleeding were noted. At the 12-month follow-up, the recurrence rate in the apical compartment was 0.7% (1/147) and in the anterior compartment 7.4% (11/147). The efficacy of the surgery reached 96.5%. During 12 months of follow-up, no cases of mesh exposure or chronic pelvic pain syndrome were detected. The incidence of dyspareunia de novo was observed in just one patient., Conclusions: A unilateral sacrospinous fixation with a synthetic mesh (apical sling) combined with anterior subfascial colporrhaphy enhances the anatomical efficacy of surgery. It also helps to avoid specific side effects of traditional sacrospinous fixation.

Introduction: Intracorporal colpotomy during radical hysterectomy for cervical cancer is discussed to be a risk factor for peritoneal dissemination of tumor cells. It might lead to increased recurrence rates after laparoscopic radical hysterectomy compared with abdominal hysterectomy, as shown by the recent LACC study. Data on the frequency or mechanisms of peritoneal contamination are missing. We aimed to analyze peritoneal contamination of cervical secretion during intracorporal colpotomy with a novel indocyaningreen (ICG)-based technique., Material and Methods: In this prospective proof-of-principle study, patients undergoing routine laparoscopic or robot-assisted hysterectomy were selected. ICG was specifically applied to the cervical surface and routine surgery was performed. During colpotomy, pictures under white and fluorescence light were taken to evaluate frequency of contamination., Results: By using cervically applied ICG we were able to visualize directly peritoneal contamination with cervical secretion during intracorporal colpotomy. We detected peritoneal contamination in 9/12 (75%) patients undergoing routine laparoscopic hysterectomy. Contamination of laparoscopic instruments occurred in 60% of the patients. When contamination occurred, it was routinely detectable during all steps of colpotomy. There were no adverse effects during surgery., Conclusions: Peritoneal contamination with cervical secretion frequently occurs during intracorporal colpotomy. This novel technique represents a promising tool for feasible and direct visualization of peritoneal contamination during colpotomy. The technique may be easily implemented in further studies on laparoscopic and abdominal hysterectomy and serve as a quality assessment tool for surgeons and surgical techniques., (© 2019 Nordic Federation of Societies of Obstetrics and Gynecology.)

It was reported recently that minimally invasive radical hysterectomy was associated with worse prognosis than the open abdominal counterpart for the management of early-stage cervical cancer. Uterine manipulator and intracorporeal open colpotomy may be the 2 main suspects responsible for the inferiority. We hypothesize that minimally invasive radical hysterectomy with enclosed colpotomy and without the use of a uterine manipulator will improve survival. Thus, laparoscopic radical hysterectomy with abdominal uterine manipulation and enclosed colpotomy was performed in women with early-stage cervical cancer. The round ligament, the ovary ligament, and the fallopian tube were sutured together for the abdominal manipulation of the uterus. Meanwhile, the upper vagina was ligated before colpotomy to avoid tumor spillage. There were no intraoperative and postoperative complications. The abdominal uterine manipulation and enclosed colpotomy technique, which are both safe and feasible in this study, provide a relatively tumor-free approach for minimally invasive radical hysterectomy. Further investigation of oncologic outcomes in larger prospective studies are needed to confirm our hypothesis., (Copyright © 2019. Published by Elsevier Inc.)

Background: Untreated symptomatic imperforate hymens at birth can result in renal complications and ascending infection. Although guidelines recommend incision and drainage, little is discussed regarding postoperative management and surveillance., Case: A 2-day-old infant with symptomatic imperforate hymen (hydrometrocolpos and hydronephrosis) underwent incision and drainage using sterile technique. On postoperative day 19 she developed hymen reclosure, fluid reaccumulation, and concern for sepsis. After stabilization, redrainage was performed in the operating room with interrupted suture placement around an annular incision. She rapidly improved. Serial postoperative follow-up was performed to ensure ongoing patency of the hymen during healing., Summary and Conclusion: Neonatal hymenotomies can have postoperative complications. We recommend consideration of annular suture placement and close follow-up, because of risk for reclosure and rapid deterioration from infection in this age range., (Copyright © 2019 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate a method of vaginal closure with the EndoGIA surgical stapler (Medtronic, Istanbul, Turkey) to prevent tumor spillage in laparoscopic radical hysterectomy., Design: A step-by-step explanation of the procedure using a video., Setting: Women's health teaching and research hospital., Patient: A 40-year-old woman with clinical stage IBI cervical squamous cell carcinoma., Interventions: Laparoscopic type C radical hysterectomy with pelvic lymph node dissection and ovarian transposition. Institutional ethical committee approval was not sought. However, the patient signed an informed consent that allows us to use her clinical data., Measurements and Main Results: Minimally invasive surgery is increasingly being used in cervical cancer surgery. However, there is a current and significant debate regarding the safety of these methods. Colpotomy, which is the last step of laparoscopic radical hysterectomy, could be related to an increased risk for tumor spillage. Vaginal closure before colpotomy may be an option to prevent this spillage. In this method, after completion of the radical hysterectomy steps, the initial 5-mm left lower quadrant trocar was changed to a 15-mm trocar to allow for the placement of an EndoGIA with a green cartridge. The uterine manipulator was removed, and the uterus was elevated with a myoma screw. Then, the stapler was placed, and we checked that no other unintended structure was included in the jaws of the stapler before the firing. The EndoGIA surgical stapler was fired 2times to close the vagina. The stapler places 2 triple-staggered rows of titanium staples and knife blade cuts simultaneously between them. Once the vagina was divided, the stapler was released. The upper part of the vaginal cuff was excised and sent to pathology as a surgical margin, and the uterus was removed through the vagina. Finally, the vaginal cuff was closed with intracorporeal suturing., Conclusion: Vaginal closure with the EndoGIA surgical stapler before colpotomy provides a safe and easy method to prevent tumor spillage and could improve the unfavorable results related to minimally invasive surgery in patients with cervical cancer., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To study perioperative period conditions of total and partial colpocleisis with severe pelvic organ prolapse (POP) in elderly patients. Methods: From Jan. 2014 to Oct. 2017 286 severe POP elderly patients underwent total or partial colpocleisis. The mean age was (76.0±5.1) years (60-90 years) . Of which, 220 patients (76.9%, 220/286) presented more than one kind of medical disease. The operative time, intraoperative blood loss, hospital stay after surgery, postoperative complications, preoperative urinary dysuria symptoms of total and partial colpocleisis in treatment of 286 patients were analyzed. Results: In 286 patients, 172 patients (60.1%) underwent total colpocleisis and 114 patients (39.9%) underwent partial colpocleisis. Totally 48 patients (16.8%) in 286 patients underwent anti-urinary incontinence procedure. The mean operating time of 286 patients was (67±22) minutes,the mean blood loss was (52± 57) ml, the mean hospital stay after surgery was (5.9±1.9) days (2-16 days) . The rate of postoperative complications was 8.7% (25/286) . Those complications including 1 case of bladder injury during operation, 3 cases of postoperative pelvic hematoma, 1 case of intestinal obstruction, 5 cases of atrial fibrillation, 10 cases of postoperative morbidity, 3 cases of pulmonary embolism, 1 case of lower limb thrombosis, 1 case of urinary retention underwent electrical stimulation treatment because of ineffective application of urinary retention catheter. The mean operating time was (67±22) minutes in total colpocleisis and (68±20) minutes in partial colpocleisis ( P> 0.05) , the mean blood loss was (58±62) ml in total colpocleisis and (41±45) ml in partial colpocleisis ( P> 0.05) , the mean hospital stay after surgery was (5.9±1.9) days in total colpocleisis and (6.0±1.8) days in partial colpocleisis ( P> 0.05) , the rate of post operative complications was 8.1%(14/172) in total colpocleisis and 9.6% (11/114) in partial colpocleisis ( P> 0.05) , respectively; those four of comparisons showed no significant difference. There were 129 patients (45.1%, 129/286) with voiding difficulty before surgery; the mean postvoid residual volumes of the above two operation types of people after operation were (35±43) and (34±41) ml, which showed no significant difference ( P> 0.05) . Conclusions: Colpocleisis is a safe and effective management in selected elderly patients with severe POP, who no longer desire to maintain vaginal coital function. There is no significant difference in the perioperative period conditions between total and partial colpocleisis. The choice of surgical procedure is based on factors such as the presence or absence of malignancy in the uterus, age and willingness of the patient, and general condition.

Background: Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure but can be challenging for many to perform as evidenced by its declining rate. Vaginal removal of the adnexal structures can be difficult because of poor visualization. Factors such as abnormal pathology, incidental finding of early-stage endometriosis or adhesions from previous cesarean section or surgery, and obesity may further complicate the procedure. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) may be performed during vaginal surgery using basic laparoscopic single-site skills as a "rescue" procedure for the complete removal of the adnexae. This allows the surgeon to complete the procedure vaginally without requiring conversion or addition of abdominal incisions. The combination of total vaginal hysterectomy (TVH) with NOTES as a "rescue" procedure may be a useful tool for gynecologic surgeons for removal of the adnexae and performance of other pelvic procedures., Study Objective: To demonstrate various common pelvic procedures that can be performed by transvaginal NOTES after completion of TVH., Design: Variety demonstrations of the transvaginal NOTES technique as a "rescure" for total vaginal hysterectomy with narrated video footage (Canadian Task Force classification III)., Setting: Academic tertiary care hospital., Patients: Patients with various surgeries including prophylactic bilateral salpingectomy, salpingo-oophorectomy, adhesiolysis, and incidental finding of superficial endometriosis resection. This video is exempt from institutional review board review at our institution., Interventions: Transvaginal NOTES adnexal surgery and other procedures using basic laparoscopic single-site surgical skills., Measurements and Main Results: Salpingectomy, oophorectomy, lysis of adhesions, and resection of endometriosis can be performed using NOTES at the time of vaginal hysterectomy., Conclusion: NOTES allows the surgeon to survey the pelvis for pathology and to complete other pelvic procedures transvaginally during TVH with no additional abdominal incisions. Transvaginal NOTES can be considered a "rescue" approach and can be a helpful tool for the pelvic surgeon., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to compare the degree of surgical smoke or vapor and lateral thermal damage caused by two different energy-based surgical devices (ESDs) used in colpotomy during total laparoscopic hysterectomy., Methods: Patients undergoing laparoscopic hysterectomy were randomly assigned to an ultrasonic ESD group (n = 20) or monopolar ESD group (n = 20). Colpotomy was performed using the assigned ESD. The degree of surgical smoke or vapor obstructing the laparoscopic view was assessed by two independent reviewers using a 5-point Likert scale, in which a higher score indicates worse visibility. The degree of the lateral thermal damage was measured as the width from the point of instrument application to the margins of the unchanged nearby tissue using a light microscope., Results: The baseline characteristics did not statistically differ between the two groups. The degree of surgical smoke or vapor obstructing vision was 1.2 ± 0.8 points in the ultrasonic group and 3.9 ± 0.7 points in the monopolar groups (p < 0.001). The lateral thermal damage was significantly increased in the monopolar group compared to in the ultrasound group (1500 µm [1200-2500 µm] vs. 950 µm [650-1725 µm], p = 0.037)., Conclusion: Ultrasonic ESD had better laparoscopic visibility and caused less lateral thermal damage during colpotomy compared to monopolar device.

Introduction and Hypothesis: Although colpocleisis is effective in selected women, the low-morbidity obliterative procedure for treating pelvic organ prolapse (POP) and its impact on postoperative quality of life (QOL) have rarely been studied. Our aim was to assess QOL in women after colpocleisis and compare it with that of women after reconstructive vaginal surgery., Methods: This retrospective cohort study included women (aged 35-85 years) with POP who underwent obliterative or reconstructive surgical correction during 2009-2015. Patients who met the inclusion criteria underwent telephone interviews that included the validated Prolapse QOL questionnaire (P-QOL Thai)., Results: Of 295 potential participants, 197 (67%) completed the questionnaire: 93 (47%) with obliterative and 104 (53%) with reconstructive surgery. Most were Thai (95.4%), multiparous (87%), and sexually inactive (76%). Their histories included hysterectomy (12%), incontinence or prolapse surgery (11%), and POP stage 3/4 (77%). Patients undergoing obliterative surgery were significantly older than those undergoing a reconstructive procedure (69 vs 58 years, P < 0.05). The obliterative group had more children, less education, and more advanced POP. There were no significant differences in operative parameters or complications. The obliterative surgery group had a significantly shorter hospital stay: median 2 (range 1-17) days vs 3 (1-20) days (P = 0.016). P-QOL scale revealed significantly less postoperative impairment in the obliterative surgery group (1.75 vs 5.26, P = 0.023). There were no significant differences in other P-QOL domains., Conclusions: Colpocleisis improves condition-specific QOL in selected patients with advanced POP and remains an option for this group. Surgeons should consider counseling elderly women with advanced POP about obliterative vaginal surgery.

The last step of laparoscopic hysterectomy when the surgeon attempts to remove the uterus and close the vaginal cuff (colpotomy and cuff closure) is considered the most challenging part of the operation, and the procedure involves a steep learning curve for surgeons. Although various methods have been described and reviewed on vaginal cuff closure in laparoscopic hysterectomy, this study is the first to describe placing a single continuous running purse-string suture using the uterine manipulator to maintain a safe distance between adjacent structures while facilitating the closure before colpotomy., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: LeFort colpocleisis is a minimally invasive surgical option for patients with pelvic organ prolapse who no longer desire sexual activity. Pelvic surgeons have limited exposure to this procedure during their training, and are therefore less likely to offer this procedure to their patients., Methods: We use a split screen live action surgery, side by side with a low cost 3D model of a prolapse to describe a LeFort colpocleisis step by step., Results: This video is an easily reproducible guide to the steps and surgical techniques necessary to successfully perform a LeFort colpocleisis. The simulation model can be used to educate and train those performing female pelvic surgery., Conclusion: Pelvic surgeons should be able to offer LeFort colpocleisis to their patients. This video may be used to facilitate the understanding and reproducibility of the procedure.

Introduction: Anterior colporrhaphy (AC) is considered a standard procedure and is performed all over the world. However, not a single step of the procedure has ever been truly standardized and the rates of failure show a wide range in the literature from 0% up to 92%. The aim of this systematic review was to evaluate the differences in technique and procedure worldwide., Methods: We performed a systematic literature search up to March 2016 using the MeSH terms "(anterior AND (colporrhaph* or colporhaph* or repair* or cystocel*)" using Preferred Reporting Items for Sytematic Reviews and Meta-Analyses (PRISMA). Only randomized controlled trials (RCT) were included in the systematic review. A 14-point checklist was used to assess the quality of surgery undertaken in each RCT., Results: Forty RCTs from all over the world were included in the review. The indication for AC was urinary incontinence and/or pelvic organ prolapse. A detailed description of colporrhaphy was not provided even in the well-conducted RCTs. The review showed differences in each step of the procedure, in perioperative care, in anesthesia and in surgeon' experience., Conclusion: Our results highlight the problems concerning AC with the great range in postoperative outcomes. There is diversity in the anatomical structures used in the repair, in perioperative care and in the procedure itself.

Background: To asses the results of laparoscopic surgical treatment of bowel endometriosis with transvaginal resection of the rectum employing ultrasonic energy retrospective study., Method: 100 patients with symptoms of narrowing or partial obstruction of colon were submitted to laparoscopic resection of rectosigmoid tract through a vaginal route. Length of surgery, blood loss, histopathological extent of rectal invasion, surgical complications, and length of hospital stay were the main analyzed outcomes., Results: Mean operative time was 281 min, blood loss was 250 ml on average, length of stay was 8 days, bowel movements were after 3.5 days, the mean length of bowel-resected segments was 13.3 cm, the disease was multifocal in 64% and multicentric in 36% of surgical specimens., Conclusion: Laparoscopically assisted vaginal resection of rectosigmoid colon affected by endometriosis using ultrasonically activated shears with mechanical intestinal anastomoses tension free is a safe and effective procedure for surgical management of severe pelvic endometriosis with bowel involvement.

Morcellation allows minimally invasive approaches to surgery even in the presence of large uteri or myomas. Recent restrictions in the use of power morcellation, as well as concerns regarding the potential for morcellation to disseminate malignant tissue, have initiated investigation and innovation to find safer methods. This review examines current techniques for tissue extraction during uterine surgery, with a focus on contained power morcellation and contained manual morcellation via mini-laparotomy or colpotomy. Videos are included to demonstrate these methods., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: The majority of patients with cystocele undergoing reconstructive surgery have combined defects of pubocervical fascia and uterosacral/cardinal ligament complex. In this regard, the simultaneous correction of both defects is rational. Furthermore, decreasing the use of synthetic materials in pelvic floor surgery is an important goal. The aim was to evaluate the objective and subjective cure rate of a hybrid technique: bilateral sacrospinous fixation using modern monofilament synthetic tape (apical sling) combined with the original technique of subfascial colporrhaphy., Materials and Methods: This prospective study involved 148 women suffering from cystocele combined with apical prolapse. We used the following criteria to evaluate the results of surgical treatment: results of the vaginal examination (POP-Q system), urodynamic tests, bladder ultrasound, special questionnaires (Pelvic Floor Distress Inventory [PFDI-20], Pelvic Floor Impact Questionnaire [PFIQ-7], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12], International Consultation on Incontinence Modular Questionnaire Short Form [ICIQ-SF]). All listed parameters were determined before the surgery and at control examinations at 1, 6, and 12 months after the treatment., Results: At the 1-year follow-up, the objective cure rate for prolapse was 97.8%. The rate of anatomical recurrence was 2.2% (3 out of 138). The following long-term complications were noted: de novo urgency and stress urinary incontinence de novo in 2 (1.4%) and 4 (2.9%) patients, respectively. Comparison of the scores by the questionnaires also revealed a significant improvement in the quality of life in the postoperative period. Patient satisfaction rate was 97.1%., Conclusion: The hybrid technique is an effective and safe uterus-sparing method for patients with advanced forms of cystocele combined with apical prolapse. This technique improves voiding function, quality of life, and provides a high satisfaction rate.

Objective: To assess the outcome of amnion vaginoplasty in cases of vaginal agenesis due to Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome managed at the authors' institution., Design: Retrospective study., Setting: Tertiary care hospital., Patient(s): Fifty women with MRKH who underwent neovaginoplasty., Intervention(s): Modified McIndoe's vaginoplasty was done in all the patients, using human amnion graft., Main Outcome Measure(s): Functional status assessed by Female Sexual Function Index, anatomic status (length and width of neovagina), and epithelialization of vagina., Result(s): Mean (±SD) vaginal length after surgery was 8.2 ± 1 cm. Mean vaginal length at 6-month follow-up in sexually active patients was significantly longer as compared with the patients who were not sexually active after surgery (8.4 ± 1.04 cm vs. 6.6 ± 2.4 cm). Mean Female Sexual Function Index score was 30.8 ± 2.1. Vaginal biopsy showed complete epithelialization of vaginal mucosa., Conclusion(s): In a developing nation like India, McIndoe's method with amnion graft seems to be a promising option owing to its low cost, easy availability, and safety, ease of the procedure not requiring any special instrument, physiologic outcome with respect to epithelialization of the vagina without hair growth, and satisfying functional outcome., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Gender-affirming surgeries in female-to-male (FtM) transgender patients include mostly hysterectomy, bilateral salpingo-oophorectomy and mastectomy. Sometimes further surgery is performed, such as phalloplasty. Colpectomy may be performed to overcome gender dysphoria and disturbing vaginal discharge; furthermore, it may be important in reducing the risk of fistulas due to the phalloplasty procedure with urethral elongation. Colpectomy prior to the reconstruction of the neourethra seems to reduce fistula rates on the very first anastomosis. Therefore, at our center, colpectomy has become a standard procedure prior to phalloplasty and metoidioplasty with urethral elongation. Colpectomy is known as a procedure with potentially serious complications, e.g., extensive bloodloss, vesicovaginal fistula or rectovaginal fistula. Colpectomy performed via the vaginal route can be a challenging procedure due to lack of exposure of the surgical field, as many patients are virginal. Therefore, we investigated whether robot-assisted laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH-BSO) followed by robot-assisted laparoscopic colpectomy (RaLC) is an alternative for the vaginal approach., Methods: Robot TLH/BSO and RaLC as a single-step procedure was performed in 36 FtM patients in a prospective cohort study., Results: Median length of the procedure was 230 min (197-278), which reduced in the second half of the patients, median blood loss was 75 mL (30-200), and median discharge was 3 days (2-3) postoperatively. One patient with a major complication (postoperative bleeding with readmission and transfusion) was reported., Conclusion: To our knowledge, this is the first report of RaLC. Our results show that RaLC combined with robot TLH-BSO is feasible as a single-step surgical procedure in FtM transgender surgery. Future studies are needed to compare this technique to the two-step surgical approach and on its outcome and complication rates of subsequent phalloplasty.

Study Objective: To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH)., Design: A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I)., Setting: A university teaching hospital., Patients: All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation., Interventions: Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany)., Measurements and Main Results: A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 μm to 5232 μm but was not significantly different between groups (median maximum thermal damage = 1043 μm [IQR, 682-1934] vs 1522 μm [IQR, 884-2144], p = .211)., Conclusion: Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To confirm the safety and feasibility outcomes of robotic radical parametrectomy and pelvic lymphadenectomy and compare the clinicopathological features of women requiring adjuvant treatment with the historical literature., Design: Retrospective cohort study and review of literature (Canadian Task Force classification II-2)., Setting: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill., Patients: All patients who underwent robotic radical parametrectomy with upper vaginectomy (RRPV), and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy at our institution between January 2007 and December 2015., Interventions: RRPV and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy. We also performed a literature review of the literature on radical parametrectomy after occult cervical carcinoma., Measurements and Main Results: Seventeen patients with invasive carcinoma of the cervix discovered after extrafascial hysterectomy underwent RRPV with bilateral pelvic lymphadenectomy. There were 2 intraoperative complications, including 1 bowel injury and 1 bladder injury. One patient required a blood transfusion of 2 units. Three patients underwent adjuvant treatment with chemoradiation with radiation-sensitizing cisplatin. One of these patients had residual carcinoma on the upper vagina, 1 patient had positive parametria and pelvic nodes, and 1 patient had positive pelvic lymph nodes. No patients experienced recurrence, and 1 patient died from unknown causes at 59.4 months after surgery. We analyzed 15 studies reported in the literature and found 238 women who underwent radical parametrectomy; however, no specific preoperative pathological features predicted outcomes, the need for adjuvant treatment, or parametrial involvement., Conclusion: RRPV is a feasible and safe treatment option. As reflected in the literature, RRPV can help avoid empiric adjuvant chemoradiation; however, no pathological features predict the need for adjuvant treatment after surgery., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: Optimized biocompatibility of new materials is a major requirement for transvaginal meshes for pelvic organ prolapse (POP) repair. Polyvinylidene fluoride (PVDF) presented good characteristics in prior animal experiments and clinical use in humans., Methods: Between 01/2012 and 04/2016 37 women underwent transvaginal repair of symptomatic prolapse of the anterior vaginal wall (cystocele) with PVDF-mesh in a single institution. A chart review for recurrence, continence, peri- and early postoperative complications was performed. Referring practitioners were interviewed by telephone and mail. Additionally patient reported outcome and satisfaction were measured by Patient Global Improvement Inventory (PGI-I) scale., Results: 34 women were eligible for a mean follow up of 19 months. The functional outcome improved significantly. One symptomatic vault prolapse (2.9%) and two reoperations for incontinence (5.9%) occurred. Two mesh exposures (5.9%) occurred and were treated conservatively. No other severe complications were registered. 87.5% of treated women felt very much better or much better and would undergo the surgery again. A cohort study including development steps in accordance with the IDEAL system is presented., Conclusions: For the first time we report on effectivity and safety of transvaginal application of PVDF-mesh in real-life practice. A prospective long-term evaluation in a registry is justified., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: To evaluate 2-year quality of life of women with pelvic organ prolapse submitted to prosthetic correction with Elevate., Methods: We enrolled 116 consecutive patients with a stage ≥ to 2 prolapse. The Prolapse Quality of Life questionnaire was administered in the preoperative time and after 2 years of follow-up. The statistical results were obtained by using the SPSS Advanced Statistical™ 11.0 Software., Results: Patient's quality of life improved substantially following prosthetic vaginal surgery. In particular, a clear improvement in the "general state of patients health" (P < 0.05), and a reduction in the daily physical, social, and psychological quality of life (P < 0.05) connected to the prolapse of pelvic organ were observed. Furthermore, a significant reduction in the percentage of patients with urinal disturbances (86.2% preoperative vs 20.7% postoperative; P < 0.05), and an improvement in patient's relations with their partners with 12 patients resuming sexual activity were found., Conclusions: This study demonstrates that prosthetic vaginal correction represents a long-term efficient clinical instrument for women with symptomatic pelvic organ prolapse. It also achieves a resolution for urinary symptomatology and embarrassment, social limitation, physical and psychological difficulties of women, which, in great part, resulted in many overcoming surgical therapy, worried about fixed outcomes.

Objective: To quantify the distance of the dissection plane from the cervicovaginal junction to the anterior peritoneal reflection for vaginal hysterectomy., Methods: This is a descriptive study examining the dissection plane for anterior colpotomy in 22 surgical patients undergoing vaginal hysterectomy and in nine cadaver specimens. Intraoperatively, the distance from the vaginal incision to the anterior peritoneal reflection was measured on the uterus after removal. In nine of these patients, this distance was also measured before anterior peritoneal incision. Embalmed cadavers with intact pelvic viscera were dissected and the distance of the same dissection plane was measured., Results: Median (interquartile range) surgical patient age was 51.5 (42-63) years and the main surgical indications were abnormal uterine bleeding and pelvic organ prolapse. In these patients, the median (interquartile range) distance from cervicovaginal incision to anterior peritoneal reflection was 3.4 (2.6-3.7) cm. In cadavers, the median (interquartile range) age was 81 (72-86) years with a measured distance of 2.7 (2.4-2.9) cm., Conclusion: When performing a vaginal hysterectomy, surgeons can expect a median (range) dissection distance of 3.4 (1.8-4.6) cm from initial incision to the peritoneal reflection for anterior colpotomy.

Background: Imperforate hymen prevents menstrual blood drainage, which causes cyclic lower abdominal pain and amenorrhea. Untreated patients might develop serious complications such as endometriosis and infertility. Hymenectomy represents the adequate treatment., Case: In a 16-year-old female virgin presented with recurrent lower abdominal pain, urine retention, and secondary amenorrhea after 3 hymenectomy surgeries. The examination revealed imperforate hymen. A fourth hymenectomy was performed with continuous locked sutures over all of the edges., Summary and Conclusion: Recurrent imperforate hymen after hymenectomy should be suspected if symptoms recur. Diagnosis can be achieved through meticulous clinical examination and appropriate imaging techniques., (Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Aim: Imperforate hymen is the most common obstructive anomaly of the female genital tract. Conventional surgical treatment for this condition is the cruciate incision made on the hymen. The aim of this study was to evaluate a novel technique that preserves virginity after hymenotomy using electrocautery., Methods: Patients diagnosed with imperforate hymen and treated with annular hymenotomy between 2009 and 2013 were included in this retrospective cohort study. Annular incision was done using electrocautery on the hymen whilst sparing the intact hymenal tissue circumferentially at least 5 mm from the base., Results: Fifteen patients were included in the study. Mean age of patients was 14.2 ± 2.2 years. The median operation time was 5 min (3-9 min). No complications occurred. During the follow-up examinations, none of the patients had hymenal closure and all had regular menstrual bleeding., Conclusion: This novel technique showed complete success without any observed complication. This technique might be a good alternative for patients seeking to preserve virginity after surgery., (© 2016 Japan Society of Obstetrics and Gynecology.)

We present the case of a young woman at 16 weeks' gestation who presented to a peripheral hospital with severe recurrent hemoperitoneum related to severe deep endometriosis infiltrating the left parametrium. She underwent 2 surgical open procedures in emergency, followed by pregnancy loss. Deep endometriosis infiltrated the rectum, the vagina, and the left parametrium, leading to stenosis of the left ureter and advanced destruction of the left kidney. Ovarian reserve was low with an antimullerian hormone level at .6 ng/mL. To improve endometriosis-related symptoms and preserve fertility, a laparoscopic conservative rectal and ureteral management was proposed with an aim to relieve symptoms, avoid further destruction of the left kidney, preserve the right splanchnic nerves and inferior hypogastric plexus, and enhance spontaneous conception. We performed a combined vaginal-laparoscopic approach that consisted of vaginal infiltration resection, adhesiolysis, rectal shaving, ureterolysis, and restoration of the permeability of the fallopian tubes. Seven months after surgery the patient spontaneously conceived and is doing well., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: We investigated parameters associated with recurrence after partial (Le Fort) colpocleisis surgery for severe pelvic organ prolapse (POP) in elderly women., Methods: A retrospective cohort study included all women who underwent partial colpocleisis in a single tertiary center from February 2007 through July 2013 for stage 3 or 4 triple compartment prolapse. Inclusion criteria were age over 60, sexually inactive, medical comorbidities, increased risk for comprehensive reconstructive pelvic surgery, and refusal or failure to use a pessary as a conservative non-surgical treatment. Exclusion criteria were post-menopausal bleeding, pelvic malignancy, and the desire to preserve coital function., Results: The study group included 47 women of mean age 77.3 ± 8.2 (range 61-91 years). All had medical comorbidities. Fourteen patients (29.8%) had undergone previous hysterectomy. All patients underwent partial colpocleisis and perineorrhaphy. Seven women (14.9%) underwent mid-urethral sling for urinary incontinence. Mean follow-up was 14.8 ± 10.3 months (range, 2-37 months) and mean hospitalization, 3.5 ± 1.5 days (range, 2-9 days). There were no intraoperative complications. Postoperative complications comprised lower urinary tract infection (n = 2). Objective cure (according to vaginal examination) was 80.9% (38/47), and subjective (according to symptoms), 91.5% (43/47). No patient regretted the loss of sexual function. The main reasons for prolapse recurrence were statistically significant longer post-operative vaginal length and wider genital hiatus., Conclusions: Objective and subjective cure rates of Le Fort colpocleisis for the treatment of severe POP were high with low morbidity. Parameters associated with prolapse recurrence were longer postoperative vaginal length and wider genital hiatus., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Posterior colpotomy incision for specimen retrieval is infrequently used in gynecologic laparoscopic surgery unless a concomitant hysterectomy is performed. We aim to describe a simple and unique technique for creating the colpotomy incision and to describe intraoperative and postoperative outcomes., Methods: Fifty patients underwent adnexal specimen retrieval through a posterior colpotomy incision. After devascularization and detachment of the adnexal specimen, the posterior cul-de-sac was visualized. The colpotomy incision was created by introducing a 12- or 15-mm laparoscopic trocar through the vagina into the posterior vaginal fornix under direct visualization. Specimens were placed into laparoscopic bags and removed through the vagina. The colpotomy incision was closed vaginally. Charts were reviewed for intraoperative and postoperative outcomes., Results: Twenty-nine women underwent adnexal surgery for an adnexal mass, 14 women underwent surgery for pelvic pain, and 7 women underwent adnexal surgery for primary prevention of malignancy. The specimens removed ranged in size from 2 to 16 cm (mean 5.7). The mean time patients were under anesthesia was 103 minutes (SD 57.3). There were no operative complications related to the colpotomy incision and no cases of postoperative vaginal cellulitis or pelvic infection were reported. Only 1 woman with a prior vaginal delivery reported dyspareunia postoperatively., Conclusion: This simple technique for posterior colpotomy incision can easily be added to the gynecologic surgeon's armamentarium and can be safely used for most women.

Background: Persistent urogenital sinus is one of the rare urogenital anomalies, which commonly presents as hydrometrocolpos. Fetal urinary ascites as a presentation of persistent urogenital sinus is extremely rare., Case Report: We report on a preterm infant with antenatal diagnosis of hydrometrocolpos and massive urinary ascites secondary to urogenital sinus without any bladder or renal abnormalities., Conclusion: This case report emphasizes the importance of maintaining a high index of suspicion in the diagnosis of persistent urogenital sinus especially in infants presenting with urinary ascites along with hydrometrocolpos.

Objective: To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD., Methods: In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy)., Results: Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy (P=0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380-5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection., Conclusion: Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure., (Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)