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Posterior colpotomy to create an access site to the pelvic cavity has been a historical "feather in the cap" of any gynecologist, who, unlike other surgeons, can access the intraperitoneal space with a hidden incision. Trends in adnexal surgical techniques in the past 35 years have favored a transabdominal endoscopic approach, which corresponds to what is espoused by all the major gynecologic societies in the world. Resident-education curricula have created a generation of gynecologic surgeons with distinguished laparoscopic hand–eye coordination required to perform complex surgical procedures previously only performed via laparotomy. Fear of making a classical vaginal incision to approach the same goal has been—and continues to be—a hurdle in minimally invasive gynecologic surgery. The advent of the vaginal–natural orifice transluminal surgery (vNOTES) technique via posterior colpotomy uniquely synthesizes the minimally invasive access point granted primarily to gynecologists with the benefits of endoscopic surgery, which has become a mainstay for gynecologic surgery. vNOTES for gynecologic adnexal surgery represents a modern "take" on a classic surgical approach and will help today's surgeons get their feathers back in their caps. (J GYNECOL SURG 40:100) [ABSTRACT FROM AUTHOR]

Objective: The goal of this research was to determine the efficacy of fractionated carbon dioxide (CO2) laser therapy for reducing symptoms of vulvar lichen sclerosus (LS). Materials and Methods: This was a prospective case series. The study participants were 23 women with active vulvar LS, confirmed via biopsy, who were abstaining from topical and systemic treatments for at least 4 weeks before enrollment. Subjects received 3–5 treatments with the CO2 laser, based on symptom improvements. The primary endpoint was a reduction by >50%, as shown by a composite examination-based and symptom-based score at 6 months post-treatment. A secondary endpoint was changes in the Vulvar Quality of Life Questionnaire and patient-supplied Patient Global Impression of Improvement (PGI) scores. A t-test was used to contrast pre-treatment and post-treatment changes in symptoms Results: From 2015 to 2020, 23 women participated in the study. The primary endpoint of >50% reduction in the composite symptom score was not significant; p = 0.08, although a reduction was significant at that time point; p = < 0.01. At 12 months a >50% reduction was significant; p = 0.03. Secondary outcomes were remarkable for significant reductions in symptoms that did not meet the >50% threshold at 6 and at 12 months. Mean satisfaction was 2.47 ± 0.61 on a 3-point scale and significantly positive PGI scores through the post-treatment follow-up time point. Conclusions: Exploration of fractionated CO2 for treating vulvar LS should be continued. (J GYNECOL SURG 39:295) [ABSTRACT FROM AUTHOR]

Objective: This article reviews the epidemiology, diagnosis, and management of vaginal vault dehiscence, and illustrates a 5-step surgical approach to laparoscopic vault repair. Methods: At a tertiary care center, surgical footage was obtained from the case of a 34-year-old female who presented 8 weeks after a total laparoscopic hysterectomy with a complete vault dehiscence. Results: Vaginal vault dehiscence complicates 0.64% to 1.35% of laparoscopic hysterectomies, and can be categorized as complete cuff dehiscence, partial cuff dehiscence; or partial thickness. Protective factors include using barbed sutures, compared to nonbarbed sutures, and laparoscopic closure, compared to vaginal closure. Smoking and low body mass index have been associated with an increased risk of dehiscence. The surgical approach to a laparoscopic repair of cuff dehiscence can be standardized in 5 reproducible steps: (1) abdominal survey; (2) bladder and/or rectal dissection; (3) vault debridement; (4) vault closure; and (5) cystoscopy. Conclusion: While uncommon, vaginal vault dehiscence is a serious complication following laparoscopic hysterectomy that requires prompt evaluation and surgical repair. (J GYNECOL SURG 39:300) [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) that affects quality of life (QoL) in millions of women in the United States and around the world. The normal position of pelvic organs relies on both the pelvic floor muscles/levator ani muscle and the connective tissue support for the uterus and vagina. Known risk factors for POP include age, parity, family history, genetic predisposition, and chronic straining. The diagnosis of POP depends mainly on history and clinical examination. After diagnosis, progression is slow, and regression is more common than expected. Treatment starts with patient education about the disorder and available treatments. It is important to note that "doing nothing" is always an option. If patient has troublesome symptoms, there are nonsurgical and surgical options. Nonsurgical options include pelvic floor muscle training and pessary therapy. Surgery is an option for patients with POP who decline nonsurgical options or for whom those options fail. Management of women with POP and other PFDs requires a multidisciplinary team to evaluate and formulate individualized plans to address the specific health and QoL issues facing each patient. (J GYNECOL SURG 39:3) [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse is a highly prevalent condition that can have a large impact on a patient's quality of life. Multiple approaches to surgical repair exist, each with a unique set of risks and benefits. For patients with apical prolapse, repair of the apex is the cornerstone of any surgical procedure. Since adaptation of robotic techniques to sacrocolpopexy were introduced in the early 2000s, the minimally invasive approach to sacrocolpopexy has surpassed open case volumes. Compared to native-tissue transvaginal procedures, minimally invasive sacrocolpopexy offers potential advantages in durability. This article reviews surgical techniques, troubleshooting, outcomes, and ongoing areas of development regarding the use of a robotic approach to prolapse surgery. (J GYNECOL SURG 39:25) [ABSTRACT FROM AUTHOR]

Vaginal hysterectomy is considered the preferred approach for benign hysterectomy due to its cost-effectiveness, safety, and low morbidity. Efforts to increase vaginal hysterectomy utilization, including endorsement by the American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists, has had limited impact on national trends. Marketing from companies and shifts in practice patterns along with lack of resident education have exacerbated the problem. Deeply engrained, though unfounded, perceived contraindications to a vaginal approach (e.g., prior surgery, nulliparity, uterine size, and risk factors for extrauterine disease) limits consideration of this approach further. This review presents evidence against these commonly perceived contraindications and provides a peer-reviewed algorithm that can be implemented to increase vaginal hysterectomy utilization safely. As minimally invasive technologies continue to evolve, surgeons have the responsibility to seek candidates that would benefit from the original—and most minimally invasive—approach to benign hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: The objective of this retrospective chart review was to assess the feasibility, potential complications, safety, and efficacy of the Prolift® system to correct uterovaginal prolapse. Materials and Methods: Subjects treated with the original Gynecare Prolift® Mesh System (Somerville, NJ) between September 2005 and March 2009 were analyzed retrospectively. Outcomes assessed included intra- and postoperative complications and anatomical success. Results: Women (149 subjects; ages: 65.2 ± 10.9 years; body mass index: 29.47 ± 5.65 kg/m2) were treated for pelvic organ prolapse (POP) using the Prolift system. Forty-eight anterior Prolift, 42 posterior Prolift, and 59 combined (total) Prolift mesh surgeries were performed in subjects with stage II or greater degrees of POP. Mean follow-up was 18.6 months. Composite surgical success was 80.5%. Pure anatomical success (Pelvic Organ Prolapse–Quantification stage < II) was 89.6%. Mean operative time was 125 ± 41 minutes. Mean intraoperative blood loss was 111.5 mL. Adverse events were minimal and included 1 (0.07%) hematoma, 3 (2%) blood losses >500 mL, 20 (13.4%) mesh exposures, and of 34 subjects with dyspareunia (14.7%), 5 reporting de novo dyspareunia. Conclusions: The Prolift mesh reconstruction procedure is safe and effective, with minimal postoperative morbidity. [ABSTRACT FROM AUTHOR]

Objective: Pudendal nerve blockade has been used for more than a century for obstetric analgesia. With the current opioid crisis, gynecologists recognize the importance of nonnarcotic alternatives for analgesia. This study assessed pudendal nerve blocking, using localization with electrical stimulation, during transvaginal reconstructive surgery, to manage postoperative pain. Materials and Methods: Subjects with pelvic organ prolapse (POP), undergoing transvaginal repair were enrolled in this pilot study. During each surgery a pudendal block was performed through the pararectal space using a stimulating electrical current to isolate the pudendal nerve via its motor action on the pelvic floor. Local anesthetic containing dexamethasone was injected bilaterally. Outcome measures assessed were total narcotic requirements, postoperative pain, and surgeon/patient satisfaction. Results: All subjects had advanced-stage POP. Ten received the block successfully, without complications. The mean time required to complete the block was 10 minutes. Only 2 subjects required 1 tablet each of hydrocodone–acetaminophen postoperatively. There were no postoperative complications. All subjects agreed that their pain management was satisfactory. Conclusions: Performing a pudendal block, using electrical stimulation during vaginal reconstructive surgery, could decrease patients' narcotic use significantly. This method is safe and efficacious, with excellent patient and surgeon acceptance. The information from this study will be used in pivotal research to test the efficacy of the method against a placebo. [ABSTRACT FROM AUTHOR]

Objective: Average operative blood loss in abdominal hysterectomy—the most common gynecologic surgery—ranges 300–400 mL. This may not be much in normal women, but women with preexisting anemia may require blood products pre- or postoperatively or have poor healing and more surgical-site infections. Minimizing blood loss in abdominal hysterectomy for leiomyomatosis uteri has been studied with limited success of gonadotropin-releasing hormone analogues and misoprostol. This study assessed the effectiveness of a single vaginal preoperative dose of misoprostol prior to open abdominal hysterectomy for reducing blood loss and drop of postoperative hemoglobin, compared to routine hysterectomy without misoprostol. Materials and Methods: This was a randomized, parallel-group, placebo-controlled interventional-drug trial with double-blinding. Each of 2 groups had 35 participants. Women randomized to group A received 2 200-μm tablets of misoprostol vaginally 30 minutes before the start of the operation. Women randomized to group B received 2 placebo tablets. Results: Both groups had comparable mean ages, body mass indices (BMIs), uterine sizes, symptoms, and medical comorbidities. The mean uterine weight in both groups was >365–391g and mean operating times (111–119 minutes) were similar in both groups. Operative blood loss was 394 ± 186 mL in the misoprostol group and 455 ± 288 mL in the placebo group, which was not significant. (p = 0.228). A difference of 61.5 mL (difference of 13%) occurred between the groups, but did not significantly affect postoperative requirements for blood products, postoperative complications, or hospital stays, which were not statistically different in the groups. Conclusions: Using a single vaginal misoprostol dose prior to total abdominal hysterectomy for large-size uteri (>12 cm) does not significantly reduce the intraoperative blood loss, drop in hemoglobin, nor need for postoperative blood transfusion. [ABSTRACT FROM AUTHOR]

Background: Prolapse coexisting with carcinoma of the cervix is a rare occurrence. There is no standardized management for this rare combined entity. Case: A 72-year-old patient with procidentia had a suspicious-looking ulcer on her prolapsed uterus. Biopsy of the cervical lesion confirmed a well-differentiated squamous-cell carcinoma. She underwent an abdominal, modified radical hysterectomy with bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, and sacrocolpopexy. Postsurgery, she received concomitant radiotherapy and chemotherapy as adjuvants. Results: At her 6-month follow-up, her vault was healthy and well-suspended. Conclusions: This was a successful abdominal approach to carcinoma of the cervix coexisting with prolapse. Sacrocolpopexy was performed as a concomitant procedure that provided standardized management for cervical carcinoma due to feasibility of bilateral pelvic lymphadenectomy along with adequate access for targeted radiotherapy without inducing any visceral symptoms. [ABSTRACT FROM AUTHOR]

Background: Opportunistic bilateral salpingectomy is one of the primary strategies available for preventing epithelial ovarian cancer. Case: An 81-year-old woman underwent a vaginal pelvic organ prolapse and anti-incontinence procedure. An opportunistic bilateral salpingectomy was performed. Pathology testing revealed an occult fallopian tube adenocarcinoma. Results: The patient underwent surgical staging by gynecologic oncology, which revealed no further malignancy. Conclusions: In the setting of an occult tubal carcinoma identified at the time of opportunistic salpingectomy, adjuvant treatment with an interval staging procedure or chemotherapy will be needed—regardless of whether or not the ovaries were concurrently removed—and can be associated with an excellent patient outcome when early stage disease is identified. (J GYNECOL SURG 36:158) [ABSTRACT FROM AUTHOR]