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Total laparoscopic hysterectomy (TLH) may be indicated in patients with deep infiltrative endometriosis (DIE) to treat severe chronic pelvic pain symptoms, recurrences, or co-existing uterine disease. This study discusses the challenges and specific operative and postoperative considerations in patients submitted to TLH and excision of DIE, in comparison with those undergoing a procedure for other benign indications.Patients undergoing TLH and excision of DIE were included (N = 18, group 1). These were matched with cases, treated with TLH for other benign indications during the same period (2010-2019), at a 2:1 ratio (N = 36, group 2). The two groups were compared with regards to their characteristics, and intraoperative and postoperative data, including operative time, estimated blood loss (EBL), hospital stays, and rates of complications.In group 1, median DIE nodule size was 2.5 cm (range: 1.3-4.2). Simple hysterectomy was performed in 10, and a more extended procedure in 8 cases. All nodules were removed from the bowel wall using the shaving technique. Average EBL was significantly higher (p = .027), and duration of surgery and hospital stays longer (p = .003, and p = .0001, respectively), in group 1 vs. group 2. The rates of long-term (L-T) complications were higher in group 1 but not to a significant level (p = .087). Analysis within the DIE group showed that operative time was significantly related to nodule size, type of hysterectomy (p = .021), presence of adenomyosis (p = .041), uterine size ≥12weeks (p = .039), and the occurrence of L-T complications (p = .016). Increasing nodule size and an extended procedure (p = .005) increased significantly the EBL, which had also a significant effect on the risk of L-T complications (p = .006).TLH in DIE patients is a different, complex and potentially more dangerous procedure compared with TLH for other benign indications. Thorough knowledge of retroperitoneal anatomy, a clear operative plan, and excellent laparoscopic skills are necessary for concomitant radical excision of lesions, with low rates of adverse events.

The implementation of Enhanced Recovery After Surgery (ERAS) protocols may optimize the clinical outcome of surgical patients, by reducing the length of hospital stay (LOS) and improving the quality of recovery.This study aims to evaluate the impact of ERAS protocols in the intraoperative and postoperative course of patients undergoing pelvic floor reconstructive surgery.A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was conducted up to January 2022, using the Systematic Reviews and Meta-analyses guidelines. Search terms, such as ERAS, urogynecology, sacrocolpopexy were tailored to each database as necessary. Statistical analysis was performed using the RevMan 5.4 software. Confidence intervals (CI) were set at 95%. Mean difference and risk ratio were used in the analysis, and the results were calculated using the random effect model.Six studies that reported outcomes of 1,153 women were included. The ERAS protocols were implemented in 553 women, whereas the remaining 600 received standard perioperative care. A significantly shorter LOS (mean difference, -16.17 hours; 95% CI, -24.07 to -8.26 hours; P0.0001) and a higher proportion of patients discharged within 24 hours postoperatively was observed in ERAS patients compared with non-ERAS controls (risk ratio, 3.08; 95% CI, 2.00-4.75; P0.00001). Operative time, estimated blood loss, complications, and readmission rates did not differ between the 2 groups.Our analysis showed that ERAS protocols have a favorable impact on the perioperative course of urogynecologic populations. More research is required to determine those key components of ERAS protocols, specifically applicable and more beneficial to women with pelvic floor disorders.

Introduction: Enhanced Recovery After Surgery (ERAS) protocols consist of several evidence-based interventions that have been adopted to ameliorate perioperative care. Until this day, no such specific protocols suggested for urogynecology patients, exist. However, there are recent efforts towards the development of such protocols, as it has been shown to have beneficial effects among patients undergoing other gynecological procedures. This review aims to collect and analyze data in the published literature regarding implementation of an enhanced recovery after surgery pathway in a urogynecology population. Material and Methods: An extensive search of the PubMed/Medline and the Cochrane Database was conducted using the following terms: Enhance Recovery After Surgery combined with pelvic floor reconstructive surgery and urogynecology. Related articles from the latest two decades up to May 2021 were scanned for relevance. Results: The interventions concerning the implementation of an enhanced recovery pathway after urogynecologic procedures include preoperative, intraoperative, and postoperative recommendations. The main key items in these protocols comprise of patient education, optimization of comorbid conditions, diet, bowel preparation, antibiotic prophylaxis, fluid intake, anesthesiologic agents, early ambulation, postoperative analgesia, thromboprophylaxis and guidance after discharge. Conclusions: Implementation of an ERAS protocol in urogynecology-specific population has been proven to have a beneficial effect on decreasing hospital stay without increasing the rate of post-operative complications. Nonetheless, the scarcity of evidence-based studies in the literature, regarding the implementation of an ERAS protocol in gynecologic pelvic floor reconstructive surgery is apparent. Hence, further research is required with studies targeted towards urogynecology for safer conclusions to be made.

Background Breast cancer (BC) is the most common female cancer worldwide. Menopausal symptoms are a well-known side effect in women with BC and have a significant negative impact on quality of life (QoL) and sexuality. Nowadays, hormonal replacement therapy and local estrogens are the most common prescriptions to treat vulvovaginal (VVA) symptoms. However, in women with a history of BC, proper therapy for such conditions remains an often inadequately addressed clinical problem. A treatment with microablative fractional CO2 laser (MLT) can produce a remodeling of the vaginal connective tissue without causing damage to the surrounding tissue. The aim of this pilot study is to assess the efficacy and safety of MLT for treating VVA symptoms in women with a history of BC at 20-week follow-up since the first laser treatment. Patients and Methods Women with BC and VVA symptoms were enrolled in the study and treated with 5 laser applications (one every 4 weeks). The rate of satisfied patients at 20 weeks of follow-up was evaluated with a 5-point Likert scale. Changes of the Vaginal Health Index (VHI) after treatment was compared with baseline. Effects of the laser treatment on VVA symptoms was measured using a 10-cm visual analog scale (VAS). Changes in overall QoL were assessed with a generic QoL questionnaire: the Short Form 12 (SF-12) that we analyzed considering its physical (PCS12) and mental (MCS12) domains. Sexual function was evaluated by the Female Sexual Function Index (FSFI). Results In this prospective cohort study, we enrolled 40 women with a history of BC and who currently were or (Group 2) who had been (Group 1) on treatment with endocrine therapy for their condition. Six (15.0%) women were very satisfied, 25 (62.5%) were satisfied, 6 (15.0%) were uncertain, and 3 (7.5%) were dissatisfied with the MLT. VVA symptoms and VHI improved significantly at 20 weeks from baseline (P .05). In terms of QoL measured by the SF-12, the PCS12 and the MCS12 significantly improved at the 20-week follow-up. A significant improvement in total FSFI and in all domains was reported in both study groups (P .05). Conclusion MLT was safe and effective in treating VVA symptoms in women with a history of BC, irrespective of being previously or currently on endocrine therapies.

Aims The decision on the appropriate type of anesthesia for pelvic floor repair depends on a variety of factors including patients' age, performance status, comorbidities, cost-effectiveness and personal preferences. We aim to review the literature on urogynecological procedures performed under local anesthesia (LA). Methods A systematic search of four electronic databases was conducted for articles published up to May 2020. Studies reporting outcomes of women who underwent pelvic floor reconstructive surgery under LA with or without sedation, were considered eligible. Results Nineteen studies (14 noncomparative and 5 comparative), including 1626 cases of urogynecological procedures under LA were recruited. Meta-analysis revealed significantly lower mean pain scores in LA group compared to general-regional anesthesia one (GA/RA) at both 4-6 h and 8-18 h postoperatively (160 patients; mean difference [MD], -1.70; 95% confidence interval [CI]: -3.12, -0.28; p = 0.02 and 160 patients; MD, -0.72; 95% CI: -1.17, 0.27; p = 0.002, respectively). Pain scores at >24 h did not differ among the two groups (160 patients; MD, -0.28; 95% CI: -0.60-0.05; p = 0.10). Intra- and postoperatively morphine use was not different among patients who received LA and GA during prolapse surgery while nausea rates were significantly lower in LA group compared to RA group 8 h postoperatively. Conclusions LA with or without sedation represents a safe and efficient alternative anesthetic technique for urogynecological procedures with improved pain scores in up to 18 h postoperatively especially in patients who underwent surgery for SUI. LA is feasible and could be offered to patients undergoing pelvic floor surgery allowing a prompt postoperative recovery.

Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids.The aim of this study was to evaluate the impact of the use of preemptive local analgesia (LA) on postoperative pain and perioperative outcomes for women undergoing VH.A systematic search of 4 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL Register of Controlled Trials, and Clinicaltrials.gov ) was performed for articles published up to January 2021. All randomized controlled trials that presented outcomes of patients who underwent VH due to pelvic floor disorders or other benign gynecological disorders and received local infiltration analgesia were finally included.A total of 5 studies with 277 women (138 LA group vs 199 no-LA group) who underwent a VH were included in the present meta-analysis. Mean pain scores at both 30 minutes to 2 hours and 3 to 6 hours postoperatively were significantly lower in the LA group compared with the non-LA group (220 patients: mean difference [MD], -1.75; 95% confidence interval [CI], -2.77 to -0.74; P = 0.0007; and 220 patients: MD, -1.68; 95% CI, -2.28 to 1.09; P0.00001, respectively). Morphine/narcotic opioid-based consumption up to 24 hours postoperatively was significantly reduced in the LA group compared with the non-LA group (197 patients MD, -9.47 mg; 95% CI, -16.51 to -2.43; P = 0.008).The use of preemptive LA during VH seems to be beneficial especially with regard to short-term postoperative pain and opioid use. However, further studies are needed to identify the optimal anesthetic regimen, the dosage, and sites of application aiming to achieve the optimal benefit in the postoperative management.

Background: To investigate whether deep neuromuscular blockade (NMB) improves surgical conditions and postoperative pain compared to moderate block, in patients undergoing gynecologic laparoscopic surgery. Methods: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients, who were randomly assigned to one of the following two groups: patients in the first group received deep NMB (PTC 0-1) and in the other, moderate NMB (TOF 0-1). Primary outcomes included assessing the surgical conditions using a four-grade scale, ranging from 0 (extremely poor) to 3 (optimal), and patients’ postoperative pain was evaluated with a five-grade Likert scale and the analgesic consumption. Results: 144 patients were analyzed as follows: 73 patients received deep NMB and 71 moderate NMB. Mean surgical field scores were comparable between the two groups (2.44 for moderate vs. 2.68 for deep NMB). Regarding postoperative pain scores, the patients in the deep NMB experienced significantly less pain than in the group of moderate NMB (0.79 vs. 1.58, p < 0.001). Moreover, when the consumption of analgesic drugs was compared, the moderate NMB group needed more extra opioid analgesia than the deep NMB group (18.3% vs. 4.1%, p = 0.007). From the secondary endpoints, an interesting finding of the study was that patients on deep NMB had significantly fewer incidents of subcutaneous emphysema. Conclusions: Our data show that, during the performance of gynecologic laparoscopic surgery, deep NMB offers no advantage of operating filed conditions compared with moderate NMB. Patients may benefit from the deep block as it may reduce postoperative pain.

Various surgical techniques have been described for vaginal vault prolapse repair, but the best surgical approach is still to be proven. The aim of this study is to report the long-term objective and subjective outcomes of women who underwent iliococcygeus fixation for the treatment of vaginal vault prolapse with a minimum follow-up of 10 years. Women with symptomatic vaginal vault prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) who had previously undergone hysterectomy for any reason were prospectively enrolled and treated with iliococcygeus fixation. Subjective success was defined as Patient Global Impression of Improvement (PGI-I) ≤ 2 and an absence of bulging symptoms. Objective success was defined as stage of prolapse < 2 in all compartments. Overall success rate was defined as women without prolapse symptoms, PGI-I ≤ 2, stage of prolapse < 2, and no need for other surgery. Prolpase Quality of Life (P-QOL) questionnaires were completed at the preoperative visit and at every follow-up visit. Multiple logistic regression was performed to identify factors involved in the risk of recurrent POP. After a median (range) follow-up of 120 (120–132) months, the subjective, objective, and overall cure rates were 82% (32/39), 74.4% (29/39), and 74.4% (29/39), respectively. Only stage IV vault descensus independently predicted POP recurrence after ICG (OR: 7.66 [95% CI: 1.21–9.02]; p

Purpose: This study aimed to clarify the efficacy of intravaginal CO2-laser treatment in postmenopausal women with genitourinary syndrome of menopause (GSM). Materials and methods: This double-blind, randomized, sham-controlled trial included postmenopausal women diagnosed with GSM and bothersome dryness and dyspareunia. Treatment consisted of three sessions. Active CO2-laser treatments (active group) were compared to sham treatments (sham group) with the primary endpoints being changes in dryness and dyspareunia intensity, as assessed by the 10-cm visual analog scale. Secondary endpoints were as follows: changes in Female Sexual Function Index (FSFI; total score and all domains), itching, burning, dysuria, and Urogenital Distress Inventory (UDI-6); incidence of symptoms; and presence of adverse events. All outcomes were evaluated at baseline and 4 months post baseline. Results: Fifty-eight women (28 in the active group and 30 in the sham group) were eligible for inclusion. In the active group, dryness, dyspareunia, FSFI (total score), itching, burning, dysuria, and UDI-6 were significantly improved (mean [standard deviation] –5.6 [2.8], −6 [2.6], 12.3 [8.9], −2.9 [2.8], −2.3 [2.8], −0.9 [2.1], and −8.0 [15.3], respectively). In the sham group, dryness, itching, and burning were significantly improved (–1.9 [2], −1.4 [1.9], and −1 [1.9], respectively). All changes were in favor of the active group. After completion of the protocol, the proportion of participants with dryness, dyspareunia, and sexual dysfunction was significantly lower in the active group compared to those in the sham group (all p < 0.005). Conclusions: CO2 laser could be proposed as an effective alternative treatment for the management of GSM as it is superior to sham treatments.

Reviews assessing mirabegron's safety and efficacy, synthesize data from both genders, without providing specific details for female patients with OAB. The aim of this study is to qualitatively and quantitatively synthesize data evaluating mirabegron's use on female patients with OAB. PubMed/Scopus/Cochrane library/Web of Knowledge were searched for full texted, published in English-language and in peer-reviewed journals, up to November 2019, using the keyword "mirabegron".Jadad score modified by adding allocation concealment, MINORS and RoB were used for the Methodological quality and risk of bias assessment. Twenty-one studies were included in this review;7 RCTs, 3 non-RCTs and 11 observational studies. Controlled trials were of unclear (75%), high (12.5%) or serious risk (12.5%) of bias. Twelve weeks of mirabegron use resulted in significant decrease of urgency, frequency, nocturia and UUI by 1.3-2.2,2.04-2.33,0.42-0.5 and 0.9-1.04 episodes/24 h, respectively. Quality of life and sexual health was improved significantly. Sexual dysfunction decreased from 98% (84/85) at baseline, to 60% (51/85) after 12-weeks of mirabegron (p-value 0.001). Mirabegron had the same efficacy as anticholinergics in improving all OAB symptoms but with fewer adverse events. Hypertension and antimuscarinics' effects (i.e dry mouth, constipation) had an incidence of 2% (28/1221) and 1.9% (23/1221) when mirabegron was administered, respectively. Mirabegron is a safe and effective alternative therapy for females with OAB. However, there is a paucity of high-quality RCTs, with large sample sizes, long-term follow-up focusing on mirabegron's comparison to other therapies, quality of life and sexual health of female patients with OAB.

This study aims to assess the effectiveness of the non-ablative photothermal erbium laser (Er:YAG laser) for managing anterior and/or posterior vaginal compartment prolapse.A randomized, single-blind, 1:1 trial was performed comparing Er:YAG laser treatment to watchful waiting in postmenopausal women with symptomatic cystocele and/or rectocele stage 2 or 3 who opted to undergo surgery due to bothersome prolapse symptoms. Three Er:YAG laser treatments at monthly intervals were applied for the Er:YAG laser group, while there was no treatment for the watchful-waiting group. The primary outcome was the proportion of patients with stage 0 or 1 following laser treatment, while secondary outcomes included the Pelvic Organ Prolapse Quantification System (POP-Q points), Pelvic Floor Distress Inventory Questionnaire short-form, Pelvic Floor Impact Questionnaire short-form, and Patients Global Impression of Improvement (PGI-I). All outcomes were evaluated at baseline and 4 months post baseline.Thirty women (15 vs. 15) were eligible to be included. No participants (0%) in either group had POP-Q stage 0 or 1 at 4 months. Moreover, no change was present in the secondary outcomes. In the PGI-I, 2/15 (14%) and 0/15 (0%) participants declared much better/very much better in the laser and watchful-waiting group, respectively.The findings of this study do not support use of the intravaginal Er:YAG laser for treatment of the anterior/posterior vaginal wall.

Genitourinary syndrome of menopause (GSM) is a new term for a condition more renowned as atrophic vaginitis. It is used to describe a variety of menopausal symptoms and signs that are related to the physical changes of the vulva, vagina and lower urinary tract. The etiology of GSM is secondary to decreased levels of endogenous estrogens and represents a common but underreported condition. In this update we present novel minimal invasive procedures that may benefit GSM symptoms making particular focus on platelet-rich plasma (PRP) treatment, hyaluronic acid (HA) treatment and energy-based devices (CO2 laser, YAG laser, radiofrequency device and high intensity focused ultrasounds). Currently, PRP has becoming popular as a non-operative treatment option for GSM symptoms. The principle underlying PRP treatment has to do with its ability to reproduce natural mechanisms of cell regeneration through the sequential secretion of numerous growth factors. Moreover, HA has been widely used as an important ingredient in topical hydrating and lubricating gels or injected for conditions such as dyspareunia. Lately, it has also been used as a new tool to treat age-related fat lysis of the female genitalia and especially the labia majora. Τhe Energy based devices have been recently suggested for the management of GSM. They utilize technologies such as laser, electromagnetic waves and high intensity focused ultrasounds to focus energy in the vaginal wall heating the targeted tissue at various depths without causing any pain or needing a recovery time. These minimal invasive procedures appear to be promising options for the treatment of GSM symptoms. However, further studies are necessary to evaluate more thoroughly the effectiveness and safety of these procedure and assess medium and long term results.

The aim of this review is to investigate and compare all laparoscopic techniques that can be used in the surgical repair of advanced uterine prolapse. A systematic search of the PubMed, Scopus, Cochrane CENTRAL, and Clinicaltrials.gov databases was performed for articles published up to December 2020, reporting data on the treatment of severe uterine prolapse using laparoscopic procedures. Only studies in the English language, with a patient sample of ≥20 and a follow-up time of ≥12 months were included. The final synthesis of this review consisted of six studies. The main laparoscopic procedures reported were vaginally assisted laparoscopic sacrocolpopexy, vaginally assisted laparoscopic uterine sacropexy, laparoscopic sacrocolpopexy with laparoscopic supracervical hysterectomy, laparoscopic inguinal ligament suspension with uterine preservation, and laparoscopic uterosacral ligament suspension combined with trachelectomy. All procedures involved mesh placement, except for laparoscopic uterosacral ligament suspension. All procedures reported anatomical cure rates > 90%. Vaginally assisted laparoscopic sacrocolpopexy had the largest amount of intraoperative blood loss whilst vaginally assisted laparoscopic uterine sacropexy was associated with bladder injuries intraoperatively. All vaginally assisted procedures reported cases of mesh extrusion postoperatively. Laparoscopic inguinal ligament suspension was the operation with the longest mean operative and hospitalization time. Conversions were not reported. The present study shows that minimally invasive surgery can be used efficiently as an alternative to open surgery in the treatment of severe uterine prolapse.

Objectives The aim of the study was to evaluate the efficacy and safety of platelet-rich plasma (PRP) for the treatment of stress urinary incontinence (SUI). Methods This was a prospective observational pilot study conducted in a tertiary referral unit, enrolling women with SUI booked for SUI surgery. A total of 20 consecutive women met the inclusion criteria and attended all follow-ups. All participants underwent 2 PRP injections into the lower one third of the anterior vaginal wall at 4- to 6-week intervals. At baseline, they underwent urodynamic studies, a 1-hour pad test, and completed the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms and King's Health Questionnaire. At follow-up visits (1, 3, and 6 months), patients underwent the 1-hour pad test and completed the King's Health Questionnaire, International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, and Patient Global Impression Scale of Improvement. Primary outcome was to evaluate posttreatment SUI. Secondary outcomes included assessment of patient-reported questionnaires, assessment of urine loss (1-hour pad test), and the level of discomfort during injections (visual analog scale score). Statistical analysis was performed before PRP and 1, 3, and 6 months after the last treatment. Results A significant improvement in SUI symptoms was observed 3 months after treatment with a further improvement at 6 months. A mean reduction of50.2% in urine loss was observed in the 1-hour pad test. At the 6-month follow-up, 80.0% of women reported to be at least improved. No adverse effects were observed. Conclusions Platelet-rich plasma injections were both effective and safe at least in the short term and could be offered as an alternative outpatient procedure for the treatment of SUI. However, these encouraging findings warrant further investigation with randomized controlled trials.

The differential diagnosis of a sudden protrusion of a large vaginal mass includes a uterine or vaginal vault prolapse, a pedunculated uterine leiomyoma or leiomyosarcoma, a uterine stromal tumor or a giant polyp.

Aim of the video In this video, we present the case of a late-detected sinus formation 4 years after a TOT placement. Method A combined surgical approach (transvaginal and transcutaneous routes) performed by a urogynecologist and an orthopaedic surgeon was chosen to carry out a radical en bloc excision of the sinus tract with the right half of the tape. This combined approach has the advantage of completely removing the biofilm adhered to the surface of the tape and the surrounding tissues, thus making antibiotic therapy more effective. Conclusion Surgical removal of these microbial commmunities is very important for the resolution of device-related infections. Severe infectious complications of transobturator slings should be managed by a tertiary multidisciplinary team to optimize patient care.

Objectives: Sexual dysfunction and radiation cystitis are common adverse events following radiotherapy for gynecological cancer (GC). This study aims to assess the efficacy of intravaginal ...

A systematic review and meta-analysis was undertaken to assess the efficacy and safety of intravaginal energy-based therapies (laser and radiofrequency) on sexual health of cancer survivors (CS) (breast cancer (BCS) and/or gynecological cancer (GCS)). PubMed, Scopus, Web of Science, and Cochrane Library were searched until 21/02/2019. Quality of reporting, methodology, and body of evidence were assessed using STROBE, MINORS, and GRADE. Primary outcomes were dyspareunia, dryness, and sexual health (FSFI, FSDS-R). Secondary outcomes were burning, itching, dysuria, incontinence, Vaginal Health Index Score (VHIS), microbiome-cytokine evaluation, and adverse events. Main analyses, subgroup analyses, and sensitivity analyses were performed. Eight observational studies (n = 274) were eligible for inclusion. None of the studies evaluated radiofrequency. BCS and BCS-GCS were included in 87% and 13% of studies, respectively. All primary outcomes improved significantly with the exception of FSDS-R (dyspareunia (5 studies (n = 233), standardized mean difference (StdMD) (− 1.17), 95%CI [− 1.59, − 0.75]; p < 0.001; I2= 55%), vaginal dryness (4 studies (n = 183), StdMD (− 1.98), 95%CI [− 3.31, − 0.65]; p = 0.003; I2= 91%), FSFI (2 studies, n = 28, MD (12.79), 95%CI [7.69, 17.89]; p < 0.001; I2= 0%). Itching, dysuria, and VHIS increased significantly, while burning was not improved. Serious adverse events were not observed by any of the studies. Intravaginal laser therapies appear to have a positive effect on dyspareunia, vaginal dryness, and FSFI of CS. However, the quality of evidence is “very low,” with no data on intravaginal radiofrequency therapy. Further research with high-quality RCTs and long-term follow-up is needed to evaluate the value of energy-based devices as a therapeutic option for CS with sexual problems.

The perioperative period poses a risk for anemia due to the high prevalence of pre-existing anemia secondary to underlying pathologies in patients who are candidates for surgery, and as a result of the increased blood loss caused by surgery. Pre-operative anemia is an independent risk factor associated with higher risk of blood transfusion and negative surgery outcomes. Anemia and iron deficiency (ID), the main causes of pre-operative anemia, can be easily diagnosed with blood testing and are readily treated before elective surgery. However, pre-surgical screening and treatment of anemia and ID are frequently overlooked. These topics were presented and discussed at the symposium entitled "Recovery after Surgery: Don't Forget to Check Iron Status Before", held at the 11th Annual Meeting of the European Urogynaecological Association (EUGA) in October 2018 in Milan. The objectives of the symposium were to stress the high prevalence and the consequences of pre-operative anemia, illustrated with three clinical cases of women undergoing surgery, and to choose the best option for iron supplementation. In conclusion, it is essential to take time to diagnose and treat iron deficiency anemia (IDA) before surgery. The first-line treatment is oral iron when surgery can be delayed and when there is no intolerance to oral treatment or inefficient uptake, as in the case of iron sequestration or absorption disorders. Among iron preparations, ferrous sulfate in a polymeric complex (FSPC) was found to be one of the treatments of choice to improve hemoglobin iron stores and quality of life in IDA patients.

STUDY OBJECTIVE Τo investigate whether the use of vasopressin played an important role in the safe expansion of the indications of laparoscopic myomectomy in our practice. DESIGN A retrospective comparison of prospectively collected data (Canadian Task Force classification II2). SETTING A gynecologic endoscopy unit in a tertiary university hospital. PATIENTS One hundred fifty patients undergoing laparoscopic myomectomy; 50 were treated without the use of any vasoconstrictive agent (group 1), and 100 were treated with intraoperative intramyometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2). INTERVENTIONS Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS We compared the 2 groups in terms of size, number, and type of myomas; estimated blood loss (EBL); procedure length; transfusion rates; laparoconversion rates; and rates of complications. Two cases in group 1 (4%) were laparoconverted versus none (0%) in group 2. Overall, the mean EBL was 321.8 ± 246.0 mL in group 1 compared with 147.8 ± 171.8 mL in group 2, respectively (p

Genitourinary syndrome of menopause (GSM) is a common condition affecting up to 50% of postmenopausal women and up to 70% of postmenopausal breast cancer survivors. GSM is a chronic condition with ...

Pelvic floor disorders (PFDs) are a common and complex problem encompassing a broad spectrum of conditions such as urinary incontinence, voiding difficulties, pelvic organ prolapse, anal incontinence, and chronic pelvic pain. The initial assessment of women with PFDs is based on a detailed and focused history and a holistic clinical evaluation of the pelvic floor. Other investigations may be used in clinical practice for the determination of the pathophysiology and the severity of the PFDs. In the field of urogynecology, urodynamic studies, ultrasound, and magnetic resonance imaging of the pelvic floor are currently implemented in the diagnostic work-up of women with PFDs. These provide valuable information not only on the anatomic integrity but also on the function of the pelvic floor which may not be apparent from the clinical examination. The provision of such information is complementary to the patient's symptoms and degree of bother and enables the implementation of a targeted treatment plan, thus maximizing the likelihood of cure and minimizing the risk of treatment complications.

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients’ satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

To evaluate the safety and efficacy of transvaginal fractional microablative COThis is a retrospective analysis of prospectively collected data. Postmenopausal women affected by at least one urinary symptom (urinary frequency, urgency incontinence, stress urinary incontinence) and VVA symptom each (dryness, dyspareunia, itching, burning) were enrolled. Our population was divided into two groups in relation to the onset of urinary symptoms, prior to or after menopause. Women were treated with three COSixty-one women were enrolled in this study. Overall, at T1 MLT brought to a significant improvement in urinary symptoms (P 0.05) in women with urinary symptoms started after the menopause (Group B), contrary to the ones with urinary symptoms started before the menopause (Group A). Specifically, urinary frequency significantly improved only in Group B (P 0.05), while urgency incontinence, significantly reduced in both groups (P 0.05). Stress urinary incontinence did not significantly improve in both groups (P 0.05). Secondary, all VVA symptoms showed a statistically significant improvement (P 0.05) at 16 weeks from baseline; no differences were registered between groups. No adverse events were recorded.This study confirms the safety and efficacy of CO

Pelvic organ prolapse (POP) is the falling, slipping, or downward displacement of the uterus and/or vaginal compartments and neighboring organs such as the bladder, rectum, or bowel. The diagnosis includes clinical evidence of POP and symptoms related to the “downward displacement” of a pelvic organ (i.e., bulge sensation, feeling of pelvic pressure, bladder storage symptoms, urinary incontinence (UI), recurrent UTIs, etc.). The POP symptoms and their impact on patients’ quality of life and sexual function may be assessed using specifically designed questionnaires named patient-reported outcomes (PROs). In addition, PROs may assess patients’ expectations of their therapeutic management and their satisfaction. Moving toward the patient-centered medicine, PROs should be included in the day-to-day clinical practice and in research studies as they provide better communication between patients and clinician and understanding of the best therapeutic management. Furthermore, guidelines of reporting surgical outcomes suggest evaluation not only of objective but also of subjective and quality of life measures. However, a solid document including all POP components is not currently available. This chapter aims to identify and review the currently available PROs that could be used in women with POP.

In this video we present the surgical management of a 59-year-old woman with stress urinary incontinece (SUI) and pelvic organ prolapse (POP) who had a history of rheumatoid arthritis and endometrial hyperplasia with atypia. A concomitant laparoscopic hysterectomy with bilateral oophorectomy and a multi-compartment laparoscopic native tissue repair of the POP, combined with a Burch urethropexy, was performed to restore pelvic floor defects and treat the underlying endometrial pathology. Total laparoscopic multi-compartment repair of POP and/or SUI using native tissue appears to be a viable alternative to both laparoscopic procedures using synthetic meshes and vaginal native tissue repairs. Although not a routine option for the majority of patients with POP and SUI, this procedure may be offered in selected cases, where native tissue repair of the pelvic floor is preferred.

AIM Laparoscopic myomectomy may be associated with considerable blood loss, especially in patients in whom no specific hemostatic measures are used. We conducted this retrospective comparative study to investigate whether misoprosol is an effective and safe alternative to vasopressin when used as single hemostatic agent in laparoscopic myomectomy. METHODS Two hundred cases undergoing laparoscopic myomectomy (-ies), were included. Of these, 50 pre-treated with vaginal misoprostol 400mcg 1 h before surgery (group 1), were compared with two historic consecutive groups: 100 patients treated with intraoperative intra-myometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2), and 50 treated without use of any hemostatic agent (group3). RESULTS Mean procedure length did not differ significantly between the three groups (127.9 vs 100.6 vs 130.8 min). Mean estimated blood loss (EBL) was 179.7 ± 200.0 mL in group 1, compared with 147.8 ± 171.8 mL in group 2 (P = 0.793) and 321.8 ± 246.0 mL in group 3, respectively (P

Breast cancer (BC) is the most common female cancer worldwide. Menopausal symptoms are a well-known side effect in women with BC and have a significant negative impact on quality of life (QoL) and sexuality. Nowadays, hormonal replacement therapy and local estrogens are the most common prescriptions to treat vulvovaginal (VVA) symptoms. However, in women with a history of BC, proper therapy for such conditions remains an often inadequately addressed clinical problem. A treatment with microablative fractional COWomen with BC and VVA symptoms were enrolled in the study and treated with 5 laser applications (one every 4 weeks). The rate of satisfied patients at 20 weeks of follow-up was evaluated with a 5-point Likert scale. Changes of the Vaginal Health Index (VHI) after treatment was compared with baseline. Effects of the laser treatment on VVA symptoms was measured using a 10-cm visual analog scale (VAS). Changes in overall QoL were assessed with a generic QoL questionnaire: the Short Form 12 (SF-12) that we analyzed considering its physical (PCS12) and mental (MCS12) domains. Sexual function was evaluated by the Female Sexual Function Index (FSFI).In this prospective cohort study, we enrolled 40 women with a history of BC and who currently were or (Group 2) who had been (Group 1) on treatment with endocrine therapy for their condition. Six (15.0%) women were very satisfied, 25 (62.5%) were satisfied, 6 (15.0%) were uncertain, and 3 (7.5%) were dissatisfied with the MLT. VVA symptoms and VHI improved significantly at 20 weeks from baseline (P .05) with no differences between the 2 groups (P.05). In terms of QoL measured by the SF-12, the PCS12 and the MCS12 significantly improved at the 20-week follow-up. A significant improvement in total FSFI and in all domains was reported in both study groups (P .05) with no differences between groups (P.05).MLT was safe and effective in treating VVA symptoms in women with a history of BC, irrespective of being previously or currently on endocrine therapies.

The genitourinary syndrome of menopause (GSM) is a relatively new term for the condition previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. The term was first introduced in 2014. GSM is a chronic, progressive, vulvovaginal, sexual, and lower urinary tract condition characterized by a broad spectrum of signs and symptoms. Most of these symptoms can be attributed to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The hypoestrogenic state results in hormonal and anatomical changes in the genitourinary tract, with vaginal dryness, dyspareunia, and reduced lubrication being the most prevalent and bothersome symptoms. These can have a great impact on the quality of life (QOL) of the affected women, especially those who are sexually active. The primary goal of the treatment of GSM is to achieve the relief of symptoms. First-line treatment consists of non-hormonal therapies such as lubricants and moisturizers, while hormonal therapy with local estrogen products is generally considered the "gold standard''. Newer therapeutic approaches with selective estrogen receptor modulators (SERMs) or laser technologies can be employed as alternative options, but further research is required to investigate the viability and scope of their implementation in day-to-day clinical practice.

Vaginal hysterectomy (VH) and pelvic floor repair (PFR) for the surgical management of pelvic organ prolapse (POP) are usually performed under regional anesthesia. The aim of this study is to evaluate the feasibility of performing VH and PFR under local anesthesia and to compare postoperative pain and patient recovery parameters with patients undergoing the same surgical procedure under regional anesthesia. This was a single-center prospective cohort study of women with advanced POP. The standard care group consisted of 20 patients who underwent VH and PFR under a combined spinal-epidural (CSE) block, whereas the local anesthesia group consisted of 20 patients who underwent VH and PFR under local anesthesia and intravenous sedation. Primary outcomes included the intensity of postoperative pain and the percentage of patients with moderate/severe pain. Secondary outcomes included percentage of patients who used opioids, incidence of nausea/vomiting, level of sedation, and patient satisfaction rate. The median pain intensity at rest was significantly lower in the local anesthesia group at 2 h, 4 h, and 8 h postoperatively (median values: 0 vs 1.9, 0 vs 4.1, and 1 vs 2.7 respectively). The percentage of patients needing opioids was significantly lower for the local anesthesia group (35% vs 95%, p = 0.002). The proportion of patients presenting nausea and vomiting symptoms in the two groups was similar. Local anesthesia for patients undergoing VH and PFR has been shown to be a viable alternative to regional anesthesia, offering reduced postoperative pain and less opioid use for the first 8 h.

Aim To assess the efficacy and safety of tension-free vaginal tape-obturator (TVT-O) 13 years after implantation for the treatment of female pure stress urinary incontinence (SUI). This is the longest-term evaluation available of TVT-O outcomes. Methods A multicenter, prospective study was conducted in five tertiary referral centers in three countries. All consecutive women with urodynamically proven pure SUI treated by TVT-O were included. Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire-Short Form, Patient Global Impression of Improvement, and patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable and multivariate analyses was performed to investigate outcomes. Results One hundred sixty-eight women had TVT-O implantation. At 13 year after surgery, 150 of 157 patients (95%) declared themselves cured (P = .8). Similarly, at 10-year evaluation, 148 of 160 patients (92%) were objectively cured. No significant deterioration of objective cure rates was observed over time (P = .1). The multivariate analysis showed that previous anti-incontinence procedures and obesity independently predicted the subjective (odd ratio [OR]: 6.2 [95% confidence interval [CI], 1.8-13.6]; P = .02 and OR, 1.8 [95% CI, 1.3-3.0]; P = .03, respectively) and objective failure of TVT-O (OR, 5.8 [95% CI, 1.6-13.2]; P = .02 and OR, 1.6 [95% CI, 1.2-3.2]; P = .03, respectively). We found four cases of sling exposure; all of them occurred after the 10-year follow-up. Conclusions The 13-year results of this study showed that TVT-O is a highly effective and safe option for the treatment of SUI. We found that there is a significantly higher risk of having a sling exposure over 10 years after the procedure; however, the incidence is very low.

We present an action that can be used to study variationally the collapse of Bose-Einstein condensates. This action is real, even though it includes dissipative terms. It adopts long-range interactions between the atoms, so that there is always a stable minimum of the energy, even if the remaining number of atoms is above the number that in the case of local interactions is the critical one. The proposed action incorporates the time needed for the abrupt and delayed onset of collapse, yielding in fact its dependence on the scattering length. We show that the evolution of the condensate is equivalent to the motion of a particle in an effective potential. The particle begins its motion far from the point of stable equilibrium and it then proceeds to oscillate about that point. We prove that the resulting large oscillations in the shape of the wave function after the collapse have frequencies equal to twice the frequencies of the traps. Our results agree with the experimental observations.

For some years, the role of urodynamics (UDS) in female stress urinary incontinence (SUI) has been a topic of intense debate. The findings of the VaLUE and VUSIS-II randomised clinical trials (RCTs) published in 2012 appeared to suggest that UDS is not useful in women with uncomplicated SUI, with the result that several authoritative guidelines were amended and the routine use of UDS in this setting fell sharply. However, many experts have raised concerns about the design of these two RCTs and their subsequent interpretation - including the inappropriate generalisation of the findings beyond uncomplicated cases, which represent only a small minority of the overall patient population. In this paper, we consider a range of issues and confounding factors which raise doubts about how influential these RCTs should have been and reflect on the potential value of UDS both for objective diagnosis and patient counselling in female SUI.

Vaginally assisted laparoscopic sacrocolpopexy (VALS) is a combined vaginal and laparoscopic surgical approach that has been described for the treatment of women with a uterus who suffer from severe multicompartmental pelvic organ prolapse (POP). The aim of this study is to evaluate the long-term anatomical and functional outcomes and report the long-term mesh-related complications. This was a single-center prospective study of women with advanced POP who underwent VALS with at least 3 years of follow-up. The primary outcome was “composite surgical success” defined as: (1) no descent of the vaginal apex (point C) more than one-third into the vaginal canal and no anterior or posterior vaginal wall beyond the hymen (Ba and Bp

Objectives The aim of this prospective study was to assess the efficacy of 3, 4 or 5 CO2-laser sessions for the management of the genitourinary syndrome of menopause (GSM). Methods Postmenopausal women with moderate to severe symptoms of dyspareunia, wanting to resume/retain sexual activity, were treated with 3–5 laser sessions depending on symptom severity/presence, sexual function, clinical findings and women’s preference following the third laser application. Main outcomes Severity of dyspareunia, dryness, sexual function, sexual satisfaction and frequency of sexual intercourse defined the primary outcomes. Vaginal Maturation Value (VMV) and Vaginal Health Index Score (VHIS) defined the secondary ones. Results Fifty-five women received three sessions, 53 an extra fourth and 22 an extra fifth. Following the third, fourth and fifth laser sessions, respectively: dyspareunia completely regressed in 15/55 (27%), 32/55 (58%) and 38/47 (81%) of participants; dryness completely regressed in 20/55 (36%), 36/55 (66%) and 44/51 (86%); normal sexual function resumed in 23/55 (41%), 37/54 (69%) and 41/49 (84%); VMV regained non-atrophic values in 29/55 (53%), 38/55 (69%) and 42/50 (84%); and VHIS regained non-atrophic values in 44/55 (80%), 53/55 (96%) and 55/55 (100%) of participants. Conclusion Results of this study indicate that CO2-laser therapy may contribute to complete regression of dyspareunia and dryness and reestablishment of normal sexual function in postmenopausal women, in a dose-response manner. An extra fourth or fifth session may further increase the GSM symptom-free rate.

This retrospective case-control study aimed to compare 30 versus 40 W power of CO2 laser for the therapy of genitourinary syndrome of menopause (GSM). Postmenopausal women with severe intensity of dyspareunia and dryness were eligible to be included in this study. Primary outcomes were dyspareunia and dryness. Secondary outcomes were itching/burning, dysuria, frequency and urgency, Female Sexual Function Index (FSFI), vaginal maturation value (VMV), and Vaginal Health Index Score (VHIS). One laser therapy was applied every month for 3 months. Outcomes were evaluated at baseline and 1 month following the 3rd therapy. Fifty (25 per group) women were included in this study. In the 30-W group, mean improvement of dyspareunia, dryness, itching/burning, FSFI, VMV, and VHIS was 6.1 ± 1.7, 6.0 ± 1.9, 5.9 ± 2.0, 16.6 ± 6.7, 29.9 ± 13.0, and 11.0 ± 2.9, respectively (within group comparisons all p

OBJECTIVES During the last 2 decades, ultrasonography has been proposed for the morphologic evaluation of the urethral rhabdosphincter. The aims of this study were to evaluate the feasibility of a simple sonographic technique for the assessment of the urethral rhabdosphincter morphology by using a 2-dimensional (2D) transvaginal transducer and to evaluate any associations between the sonographic parameters of rhabdosphincter morphology with the presence of urodynamic stress incontinence (USI). METHODS This was a prospective study of women who underwent urodynamic studies and an introital 2D ultrasonography and divided in 2 groups based on the presence or absence of USI. Measurements included rhabdosphincter thickness at the 3-o'clock (right) and 9-o'clock (left) positions and the rhabdosphincter outer (Π) and inner circumference (π). Based on these values, the mean thickness of the rhabdosphincter (R + L / 2), the rhabdosphincter differential perimeter (Π - π), and area (A - α) were also calculated. RESULTS Statistical analysis showed that women with a rhabdosphincter area of less than 0.65 cm, mean thickness of less than 0.24 cm, and differential perimeter of less than 1.08 cm had 3.98, 5.67, and 5.41 times greater odds for USI, respectively. Receiver operating characteristic curve analysis results showed that the optimal cutoff values for the prediction of USI from rhabdosphincter thickness, differential perimeter. and surface area were 0.24 cm (79.6% sensitivity, 63.4% specificity), 1.08 cm (70.8% sensitivity and 69.1% specificity), and 0.65 cm (71.9% sensitivity, 57.1% specificity), respectively. CONCLUSIONS Introital ultrasonography with a 2D transvaginal probe allowed the visualization of the urethral rhabdosphincter morphology in greater than 90% of the cases. Sonographic measurements showed that patients with USI had a thinner urethral rhabdosphincter than did women with a normal sphincteric mechanism.

Introduction Laparoscopic sacrocolpopexy (LSCP) is a reference operation for apical compartment prolapse repair. Aim of this study is to describe the early and midterm postoperative MRI findings of the lumbosacral region (LSR) in patients undergoing LSCP and to detect any imaging changes that the presence of the mesh may cause on patients with preexisting degenerative disease of the LSR. Methods Patients with POP-Q grade III and IV uterovaginal or vaginal vault prolapse who were considered eligible for LSCP were invited to participate. An MRI of the LSR was performed preoperatively and then 3 and 12 months postoperatively. Patients with vaginal vault prolapse underwent LSCP, while women with uterovaginal prolapse were treated with the vaginally assisted laparoscopic sacrocolpopexy (VALS). Results A total of 30 patients were included in the study; 18 (60%) underwent LSCP and 12 (40%) VALS. On preoperative MRIs, 83.3% (25/30) of patients had degenerative changes and 70% (21/30) reported having low back pain (LBP). Postoperative MRIs did not reveal any imaging changes compared to the preoperative MRI findings both for patients with or without preexisting degenerative abnormalities of the LSR. No significant changes in the LBP score were observed postoperatively. Conclusions Any bone marrow or soft-tissue changes at MRIs of the LSR early after the insertion of a synthetic mesh, does not constitute an expected postoperative finding and should raise the suspicion of an ongoing inflammatory or infectious spinal process (spondylodiscitis). Additionally, LSCP seems to be a safe surgical approach for women with preexisting degenerative disease of the LSR.