TWO-YEAR FOLLOW-UP ON SURGICAL OUTCOMES OF vNOTES HIGH UTEROSACRAL LIGAMENT SUSPENSION FOR THE PROPHYLAXIS AND TREATMENT OF PELVIC ORGAN PROLAPSE: A MULTICENTER PROSPECTIVE COHORT STUDY.

STUDY OBJECTIVE: We aimed to evaluate the medium-term outcomes of high uterosacral ligament suspension (HUSLS) with vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) in patients either suffering from pelvic organ prolapse (POP) or undergoing routine prophylaxis to prevent post-hysterectomy vaginal vault prolapse. DESIGN: Multicenter prospective cohort study SETTING: Three tertiary care hospitals PATIENTS: Patients who received vNOTES-HUSLS between January 1, 2021 and January 1, 2023, were included in the study. INTERVENTIONS: vNOTES-HUSLS MEASUREMENTS AND MAIN RESULTS: The data collected included surgery duration, intraoperative and postoperative complications, postoperative Visual Analog Scores (VAS), and Female Sexual Function Index (FSFI) pain subdomain scores. The changes in prolapse levels were measured using modified POP-Q scores, including the C, Ba, and Bp scores recorded prior to surgery and during the postoperative follow-up examination. Patient satisfaction was assessed using the Patient Global Impression of Improvement (PGI-I) questionnaire. The final analysis included 55 women. Of these, vNOTES-HUSLS was performed in 43 patients (78.2%) to treat apical prolapse, while the remaining 12 patients (21.8%) underwent prophylaxis following hysterectomy to prevent vaginal vault prolapse. The median follow-up period was 23.5 months, with a range of 12-37 months. Ba,C, and Bp points significantly improved in patients who underwent surgery for prolapse (p<0.001). There was no recurrence in the apical compartment following vNOTES-HUSLS for both performed prophylactic and treatment purposes after hysterectomy. Two (3.6%) patients were diagnosed with stage 3 anterior compartment prolapse. The overall vNOTES-HUSLS success rate was 96.4% at approximately two years follow-up. Bladder injury was detected as an intraoperative complication in one patient (1.8%). The overall satisfaction rate was 98.1% at the final follow-up. CONCLUSION: vNOTES-HUSLS was effective in the treatment and prophylaxis of apical prolapse, demonstrating high anatomical success rates. The procedure demonstrated a low complication rate, with intraoperative and postoperative complications each observed in 1.8%(n=1) of patients. SYNOPSIS: The Medium-Term Outcomes of vNOTES High Uterosacral Ligament Suspension.

Urge Symptoms After Vaginal Uterosacral Plication in Urinary Incontinence Patients Without Proximal Urethral Mobility: A Prospective Study.

OBJECTIVE: The primary objective of this study was to evaluate the impact of vaginal uterosacral plication on urge symptoms and quality of life in a cohort of patients with uterosacral ligament insufficiency and urge symptoms. METHODS: A total of 40 female patients were included in the study, and their posterior fornix was supported with gauze to simulate the surgical procedure. Uterosacral plication was applied to patients who experienced a decrease in urinary incontinence, nocturia, a sense of urgency, and a decrease in urge urinary incontinence symptoms or complete recovery. Images of the bladder, bladder neck, urethra, and symphysis pubis were obtained preoperatively and 1 year postoperatively. POP-Q staging was also performed, and patients completed the Overactive Bladder Evaluation Form (OAB-V8) and the Incontinence Impact Questionnaire Short Form (ICIQ-SF). RESULTS: Results from the OAB-V8 questionnaire showed that postoperative nocturia scores improved by 72.1% compared to preoperative scores, and the need to urinate at night and waking up scores improved by 68.3%. Furthermore, the mean bladder neck thickness decreased from 10 to 9.2, and the mean detrusor thickness decreased from 8.7 to 6.4, indicating a significant change (p <0.0001). The ICIQ-SF questionnaire scores also showed a 68.4% improvement in urinary incontinence affecting daily life after the operation. CONCLUSION: This study adds to the clinical evidence that uterosacral ligament support improves symptoms of overactive bladder syndromes, including urgency and nocturia. The use of pelvic floor ultrasound and the apical tamponade test is important in patient selection for the correct indication.

The effect of the distance between mesh and the urethra on sexual function in patients who underwent transobturator tape

Objective: To evaluate the effect of mesh-urethra distance on sexual function in continent patients who underwent transobturator tape (TOT) surgery due to isolated stress urinary incontinence (SUI). Material and Methods: Continent patients who had undergone TOT surgery for SUI were eligible. Objective treatment for SUI was defined as the absence of urine leakage during a stress test. Translabial perineal ultrasound was performed six months after surgery. The successful surgical group was split into two subgroups based on the distance from the posterior of the urethra at the bladder neck to the nearest proximal edge of the tape: <5 mm and >5 mm. In addition to these, band percentile, the descent of bladder neck and urethra length measured by perineal ultrasound, pubo-urethral distance, urethral thickness, detrusor thickness, cystocele descent, rectal descent, and uterine descent were evaluated. Preoperative and postoperative results of the standardized and internationally valid incontinence questionnaires Incontinence Questionnaire Urinary Incontinence Short Form and Female Sexual Function Index (FSFI) were compared between groups. Results: Eighty-two patients were included. The postoperative FSFI scores for the >5 mm group were significantly lower than those of the <5 mm group, including the postoperative FSFI average, all subscales except lubrication, and average change scores due to the operation (p<0.001). There was no statistically significant relationship between the percentile occupied and postoperative FSFI score (p=0.553), and the FSFI preoperative-postoperative difference was not significant (p=0.905). Conclusion: Sexual functions are more affected in patients with a mesh-urethra distance >5 mm as measured by perineal ultrasound.

A randomized prospective comparison of the needleless mini-sling "hammock" and "U-shape" configurations for management of stress urinary incontinence: 60-month follow-up results.

OBJECTIVE: To compare needleless mini-slings placed in a retropubic (U-shape) or trans-obturator (hammock-shape) configuration for treating stress urinary incontinence at 60th month. METHODS: All surgeries, conducted by a senior surgeon, involved objective and subjective assessments preoperatively and at 6, 12, 18, and 60 months postoperatively using cough-stress tests, ICIQ-SF, PGI-I, and a Likert scale. RESULTS: After 60 months, no significant differences were found in cure rates, mesh complications, or reinterventions between U-shaped and hammock-shaped groups. However, a significant decrease in cure rates was observed at 18 and 60 months in both groups. Notable differences in ICIQ-SF, Likert scale, and PGI-I scores were seen in the hammock-shaped group, while the U-shaped group showed differences in ICIQ-SF and PGI-I scores, but not in the Likert scale. CONCLUSION: Given the lack of significant differences, asserting the superiority of either retropubic (U-shape) or transobturatorly (hammock-shape) needleless mini-slings for treating stress urinary incontinence is challenging.

Patient Satisfaction and Bleeding Rates Following an Introital Fascial Approach for Temporary and Permanent Hymenoplasty Techniques: A Comparative Study.

BACKGROUND: Bleeding during first sexual intercourse represents a significant sociocultural concern with potential implications for some couples. OBJECTIVES: The aim of this study was to introduce a novel modification to temporary and permanent hymenoplasty and evaluate both the objective and subjective success of defined techniques by assessing surgical outcomes and patient satisfaction with either temporary or permanent hymenoplasty procedures. METHODS: A retrospective study of 246 patients was conducted between 2015 and 2023. Various parameters, including age, sexual history, pregnancies, BMI, and bleeding satisfaction, were assessed. Pain at first intercourse was rated on a visual analog scale (VAS). RESULTS: The age at the time of operation was significantly lower in patients undergoing permanent hymenoplasty compared with those undergoing temporary hymenoplasty (24.0 years [interquartile range (IQR), 22.0-26.0 years] vs 27.0 years [IQR, 26.0-29.0 years]; P < .001). Patients undergoing permanent hymenoplasty reported significantly lower VAS scores at first sexual intercourse compared with those undergoing temporary hymenoplasty (4.0 [IQR, 2.0-5.0] vs 7.0 [IQR, 6.0-7.0]; P < .001]. Satisfaction rates were high in both groups, with all temporary hymenoplasty patients satisfied with duration of bleeding compared with 78.6% (110/140) of permanent hymenoplasty patients (P < .001). CONCLUSIONS: This study introduces a novel modified temporary and permanent hymenoplasty technique to the literature and provides the first video documentation for both temporary and permanent hymenoplasty procedures. Both hymenoplasty techniques are effective and reliable. However, temporary hymenoplasty is associated with a higher bleeding rate than permanent hymenoplasty, despite resulting in higher VAS scores.

Labiaplasty Outcomes and Complications in Turkish Women: A Multicentric Study.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the outcomes, complication rates, and complication types of different labiaplasty techniques. METHODS: In this cross-sectional retrospective study, a total of 2,594 patients who underwent surgery owing to hypertrophy or asymmetry of the labium minus were retrospectively analyzed. Data were collected by individual interviews with 43 experts from different centers. The patients were between 18 and 50 years of age. During the interview information about the presence and nature of complications, and about concomitant or revision surgeries, were gathered. The surgeons who performed these surgeries were also questioned about their training and surgical experience. RESULTS: The most frequently observed complication was complete dehiscence, accounting for 29% of all complications. Complete dehiscence was most commonly seen after wedge resection (16 cases). The second most common complication was labium majus hematoma, accounting for 12.5% of all cases. Among the labiaplasty techniques, wedge resection had the highest complication rate at 3% (26 cases out of 753 patients). This was followed by composite labiaplasty at 1.2% (5 cases out of 395 patients), Z-plasty at 0.8% (1 case out of 123 patients), and trimming labiaplasty at 0.5% (7 cases out of 1,323 patients). CONCLUSION: Considering the heterogeneity and low quality of the existing studies on this subject, this study provides valuable information for surgeons practicing in this field. However, further research is clearly warranted as female genital aesthetic procedures are being performed with a steadily increasing trend.

Partner Satisfaction in Labiaplasty Patients.

BACKGROUND: Labiaplasty, which has become increasingly popular in recent years, is chosen by women for both cosmetic and functional reasons. It creates significant changes in female sexuality, resulting in high satisfaction rates, but there are limited data on its effects on male sexual response. OBJECTIVES: The aim of this study was to investigate the effects of labiaplasty on partners. METHODS: The partners of 49 patients who underwent labiaplasty between January 2020 and May 2023 were included in the study. Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EjD), Golombok-Rust Sexual Satisfaction Scale, and New Sexual Satisfaction Scale questionnaires were administered to the partners preoperatively and 6 months postoperatively. RESULTS: There was no significant difference between preoperative and postoperative responses to the MSHQ-EjD questionnaire. The postoperative increase in the New Sexual Satisfaction Scale compared with the preoperative score was statistically significant. Statistically significant positive changes were observed postoperatively in the Golombok-Rust Sexual Satisfaction Scale categories of intercourse frequency, communication, satisfaction, and nature of sexual intercourse. CONCLUSIONS: Labiaplasty operation had positive effects on male sexual response but had no effect on ejaculation function and difficulty.

A randomized, prospective, controlled study comparing uterine preserving laparoscopic lateral suspension with mesh versus laparoscopic sacrohysteropexy in the treatment of uterine prolapse.

OBJECTIVES: Pelvic organ prolapse (POP) significantly affects women's quality of life, occurring in 20-30% of females aged over 20 globally. With aging populations, demand for pelvic reconstructive surgery is rising. Patients seek anatomical restoration while preserving uterus and sexual function. Sacrohysteropexy is the gold standard for apical prolapse, but carries risks. Lateral suspension, offers safer apical and anterior correction especially for obese, sexually active women. Our prospective study compares laparoscopic sacrohysteropexy and lateral suspension objectively and subjectively. STUDY DESIGN: The study included patients who had laparoscopic lateral suspension (n = 22) or laparoscopic sacrohysteropexy (n = 22) for symptomatic stage 2 apical prolapse. Groups randomized with using block design. Anatomical cure was based on measurements taken by the same physician, unaware of intervention, before and at 12 months using POP-Q score. Pelvic floor ultrasound also used for objective rates. Subjective comparison used Prolapse Quality of Life (P-QoL), Pelvic Organ Prolapse-Symptom Score (POP-SS), Female Sexual Function Index (FSFI), Visual Analog Score (VAS), and Michigan Incontinence Severity Index (M-ISI). RESULTS: Age, BMI, parity, menopause, sexual activity, complications, showed no significant difference between groups (p > 0.05). Surgical procedure duration significantly varied between groups lateral suspension group was shorter. There was no significant difference in post operative complications. No significant differences in posterior/enterocele stages.) Anterior staging showed no significant difference in sacrouteropexy (p = 0.130), but significant difference in lateral suspension group (p < 0.001). No significant differences in pre-op and post-op PQOL, POP-SS, FSFI, and M-ISI scores between the two groups. CONCLUSION: Both methods effectively managed apical prolapse with similar outcomes. Objective measurements showed lateral suspension's superiority in reducing bladder descent.

Should sacrouterine plication be added to lateral suspension surgery? A prospective study.

AIM: Laparoscopic lateral suspension is a novel approach for repairing anterior and apical pelvic organ prolapse (POP). According to integral theory, urinary symptoms and pelvic pain are believed to originate from suspensory ligaments. We aimed to investigate the objective and subjective outcomes of adding sacroterine plication to apical prolapse surgery. METHODS: Sixty patients with Grade 2 or higher symptomatic apical POP were included in the study. The study sample was categorized into two groups: Group 1 underwent lateral suspension and Group 2 underwent lateral suspension and sacroterine plication. Anatomical cure was defined separately for the apical and anterior compartments as POP-Q scores for sites C and Ba of less than -1 cm for each compartment. A subjective cure was defined as the absence of bulge symptoms. Patient satisfaction, sexual function, prolapse-related quality of life, voiding dysfunction, nocturia, and constipation were assessed. RESULTS: In Group 1, anatomical cure rates for apical and anterior prolapse were 100% and 70%, respectively (p <0.001). In Group 2, these rates were 100% for apical prolapse and 73.3% for anterior prolapse (p <0.001). The subjective cure was 96.6% in both groups. Furthermore, improvement in sexual and urinary symptoms was more significant in the group that underwent sacroterine plication (p <0.001). CONCLUSIONS: The additional sacroterine plication (shortening) procedure with lateral suspension proved to be an effective and successful surgical approach for apical prolapse. Its routine addition to existing lateral suspension surgery can contribute significantly to the improvement of urinary and prolapse symptoms.

Development and benchmarking of a dose rate engine for raster-scanned FLASH helium ions.

BACKGROUND: Radiotherapy with charged particles at high dose and ultra-high dose rate (uHDR) is a promising technique to further increase the therapeutic index of patient treatments. Dose rate is a key quantity to predict the so-called FLASH effect at uHDR settings. However, recent works introduced varying calculation models to report dose rate, which is susceptible to the delivery method, scanning path (in active beam delivery) and beam intensity. PURPOSE: This work introduces an analytical dose rate calculation engine for raster scanned charged particle beams that is able to predict dose rate from the irradiation plan and recorded beam intensity. The importance of standardized dose rate calculation methods is explored here. METHODS: Dose is obtained with an analytical pencil beam algorithm, using pre-calculated databases for integrated depth dose distributions and lateral penumbra. Dose rate is then calculated by combining dose information with the respective particle fluence (i.e., time information) using three dose-rate-calculation models (mean, instantaneous, and threshold-based). Dose rate predictions for all three models are compared to uHDR helium ion beam (145.7 MeV/u, range in water of approximatively 14.6 cm) measurements performed at the Heidelberg Ion Beam Therapy Center (HIT) with a diamond-detector prototype. Three scanning patterns (scanned or snake-like) and four field sizes are used to investigate the dose rate differences. RESULTS: Dose rate measurements were in good agreement with in-silico generated distributions using the here introduced engine. Relative differences in dose rate were below 10% for varying depths in water, from 2.3 to 14.8 cm, as well as laterally in a near Bragg peak area. In the entrance channel of the helium ion beam, dose rates were predicted within 7% on average for varying irradiated field sizes and scanning patterns. Large differences in absolute dose rate values were observed for varying calculation methods. For raster-scanned irradiations, the deviation between mean and threshold-based dose rate at the investigated point was found to increase with the field size up to 63% for a 10 mm × 10 mm field, while no significant differences were observed for snake-like scanning paths. CONCLUSIONS: This work introduces the first dose rate calculation engine benchmarked to instantaneous dose rate, enabling dose rate predictions for physical and biophysical experiments. Dose rate is greatly affected by varying particle fluence, scanning path, and calculation method, highlighting the need for a consensus among the FLASH community on how to calculate and report dose rate in the future. The here introduced engine could help provide the necessary details for the analysis of the sparing effect and uHDR conditions.

Does the Surgical Margin Affect Sexual Function Following Linear Labiaplasty Technique?

BACKGROUND: How much labial tissue should be left after labiaplasty is a controversial issue. OBJECTIVES: The objective was to investigate the effect of residual labial tissue following labiaplasty operations on sexual function. METHODS: A total of 150 females who underwent labiaplasty between 2019 and 2021 and their partners were included in the study. In this retrospective study, linear labiaplasty technique was applied according to the patient's request. Patients were either below 1 cm or above 1 cm according to the remaining labial width at follow-up. The remaining labial tissues were classified according to the Motakef classification. Patients with a labial width above 1 cm were included in Group 1, and patients with a labial width below 1 cm were included in Group 2. Sexual function, sexual experience, body image, and erectile function of their partners were compared preoperatively and 2 years postoperatively with appropriate questionnaires. RESULTS: Sexual function, sexual experience, and body image of females improved in all patients. However, the improvement was more apparent with with remaining labial tissue of greater than 1 cm. The increase in the survey results of the partners was found to be similar. CONCLUSIONS: The sexual function of the patients was better when the width of the labium was longer than 1 cm. This may be due to better protection of the neurovascular structures. This favorable effect was also seen in the subjective evaluation of the partners.

Intrapartum ultrasound for fetal head asynclitism: Is it possible to establish a degree of asynclitism to correlate to delivery outcome?

OBJECTIVE: To investigate the role of intrapartum ultrasound (IU) in the diagnosis of asynclitism and the importance of asynclitism degree in labor outcomes. METHOD: This prospective cohort study included 41 low-risk pregnant women with fetus in singleton-vertex. The IU assessment to diagnose asynclitism was performed during labor at two specific steps, including the suspicion and/or diagnosis of labor arrest. The "four-chamber view" and "squint sign without nose" were classified as marked/severe asynclitism. The "midline deviation" and "squint sign with nose" findings were classified as moderate asynclitism. Obstetric outcomes and maternal-fetal complications were compared with the degree of asynclitism. RESULTS: Severe and moderate asynclitism was seen in 17 (41.7%), 10 (58.8%) and seven (41.2%) women, respectively. All pregnant women diagnosed with asynclitism delivered by vacuum extraction (VE) or cesarean section (CS). CS was performed in nine patients with asynclitism (52.9%). The difference between asynclitism type and VE/CS ratios was statistically significant (P = 0.039). Four fetuses with squint sign without nose delivered by VE. A significant correlation was seen between the presence of squint without nose sign and second-/third-degree perineal injury. CONCLUSION: Severe asynclitism is associated with increasing operative birth and maternal-fetal complications. Detection of asynclitism degree by IU could be useful, alerting the obstetrics team to possible perinatal problems during delivery.

Comparison of the effect of general anesthesia and spinal anesthesia technique combined with general anesthesia on intraabdominal volume during gynecological laparoscopy.

PURPOSE: We aimed to investigate the effect of spinal anesthesia which will be performed simultaneously with general anesthesia on the site of operation with the same pressure. MATERIAL AND METHOD: This study was conducted as a randomized, prospective clinical study on 40 patients who were randomly divided into two groups. Twenty women underwent general anesthesia (Group GA) and 20 women underwent spinal anesthesia with general anesthesia (Group SGA). For all cases, preoperative height, weight, waist circumference, body mass index (kg/m2 ), the distance between both spina iliaca anterior superior, the distance of the intersection of both ribs with an imaginary line drawn over the anterior axillary line, suprapubic bone-umbilical, umbilical-xiphoid, and suprapubic bone-xiphoid distance from the midline of the abdomen were measured. Moreover, while the patient was lying in the neutral position on the operating table, the height of the highest point of the abdomen to the operating table was also measured. These measurements were repeated at intra-abdominal pressure (IAP) 14 and 25 mmHg. The amount of intra-abdominal insufflated CO2 was also recorded at IAP 14 and 25 mmHg. RESULTS: When the intra-abdominal insufflation volumes of both groups were compared at 14 and 25 mmHg, respectively, there was no statistical difference (p: 0.54, p: 0.40). When 14 and 25 mmHg were compared in all cases, a statistically significant difference was observed in other measurements except in xiphoid-umbilical distance (p < 0.05). CONCLUSION: We found that spinal anesthesia combined with GA had no effect on the abdominal volume and anthropometric measurements in laparoscopic procedures.

Radical vulvectomy with right gluteal and left medial thigh V-Y advancement flap reconstruction

Vulvar cancer is rare. The vulva constitutes the external female genitalia and it is associated with the perineum with the intersection of urinary, sexual and anal systems. The deep anatomy of the perineum in the urogenital and anogenital triangle should be well-known to gynecological oncologists. Radical vulvectomy is the surgical treatment of choice in gross tumors expanding over the vulvar skin. After this type of excision, reconstruction is critically important because it is not always feasible to suture the vulvar defect in a primary manner. Thus, the reconstruction options should also be known to gynecological oncologists. Here, we present a video of radical vulvar cancer surgery, which was performed on a cadaver with gluteal and medial thigh V-Y advancement flap reconstruction.

Vaginal axis on MRI after laparoscopic lateral mesh suspension surgery: a controlled study.

INTRODUCTION AND HYPOTHESIS: Laparoscopic lateral mesh suspension (LLMS) has emerged as a practical, safe, and feasible alternative to sacrocolpopexy (SCP) for treating female genital apical prolapse. Although several prior studies have reported changes in the vaginal axis in women who have undergone SCP or sacrospinous ligament fixation (SSLF) surgery for prolapse, there is a lack of data on changes in the vaginal axis after LLMS. This study was aimed at investigating the level of anatomical correction following LLMS and comparing the vaginal axis on magnetic resonance imaging (MRI) in patients with apical genital prolapse. METHODS: Patients who underwent LLMS and a nulliparous control group were included in this observational prospective case-control study. MRI was performed on the control group and the study group pre- and postoperatively. The angle between the pubococcygeal line and the lower vaginal segment, the angle between the levator plate and the pubococcygeal line, and the angle between the lower and upper vaginal segments were measured and compared. RESULTS: The angles measured between the pubococcygeal line and the lower vaginal segment and between the levator plate and the pubococcygeal line were significantly lower in the preoperative than in the postoperative measurements (p < 0.001). All angles were found to be similar in the nulliparous women and in the patients following LLMS surgery. The Pelvic Organ Prolapse Symptom Score (POP-SS) score decreased significantly after the operation (p < 0.001). CONCLUSION: The vaginal axis was found to be near-normal in patients who underwent LLMS.

Do external female genital measurements affect genital perception and sexual function and orgasm?

OBJECTIVE: To provide baseline data for the anatomy of the external female genitalia and to investigate the correlation between those measurements and sexual function and genital perception. MATERIALS AND METHODS: This prospective cohort study consisted of 208 healthy premenopausal women. The Female Sexual Function index (FSFI) and the Female Genital Self-image scale (FGSIS) questionnaires were administered. Participants were divided into two groups according to their female sexual dysfunction (FSD) status. External genital measurements and anterior and posterior vaginal length were measured. RESULTS: The external female genital measurements were (cm, mean ± standard deviation): clitoral prepuce length 2.05±0.48; clitoral glans length 0.87±0.21; clitoral glans width 0.60±0.15; clitoris to urethra 2.24±0.55; anterior fornix depth 7.75±0.92; posterior fornix depth 9.25±0.75; labia minora width, right 2.12±0.86, left 2.20±0.96. A weak negative correlation was found between total FGSIS scores and clitoral prepuce length (p=0.01, r=-0.17), whereas a weak positive correlation was seen between total FGSIS scores and anterior-posterior vaginal lengths (p=0.04, r=0.13; p=0.02, r=0.15, respectively). No statistically significant difference was found between the genital measurements of participants with FSD (n=82, 39.4%) and those without FSD (n=126, 60.6%), and the total FSFI scores and orgasm subdomain scores. CONCLUSION: The female genital measurements were found to be distributed over a wide range. Although the relationship between genital measurements and genital perception varied, no significant relationship was found between genital measurements and sexual functions or orgasm. These findings suggest that a more cautious approach should be taken towards genital surgeries for cosmetic purposes.

Surgical anatomy of the pectineal ligament during pectopexy surgery: The relevance to the major vascular structures.

OBJECTIVE: During pectopexy surgery, the prolapsed uterus or the vaginal apex is fixed to the pectineal ligament. The anatomic structures found in the lateral part of the prevesical and paravaginal space above the obturator fossa, raise the importance of the surgical steps required to prevent complications. This study was conducted to evaluate the proximity of vascular structures to the pectineal ligament. MATERIALS AND METHODS: The distances between the surgical suturing area during pectopexy surgery and the external iliac vein, pubic anastomotic vessel (corona mortis) and obturator canal were measured bilaterally in seven fresh female cadavers. RESULTS: The total length of the pectineal ligament was 5.9±0.76 cm on the left and 6.5±1.14 cm on the right side; the midpoint of the pectineal ligament was 2.8±0.52 cm on the left and 3.6±0.47 cm on the right side. From the midpoint of the left pectineal ligament, the mean distance to the left external iliac vein was 1.04±0.23 cm, to the left corona mortis it was 2.15±0.48 cm, and to the left obturator canal it was 3.12±0.95 cm. From the midpoint of the right pectineal ligament, the mean distance to the right external iliac vein was 1.25±0.43 cm, to the right corona mortis it was 2.37±0.63 cm, and to the right obturator canal it was 3.57±0.93 cm. CONCLUSION: The anatomic findings of the study confirmed that the pectineal ligament was in close association with main vessels. The external iliac vein was measured as the closest anatomic structure to the pectineal ligament. Surgeons must be careful to minimize life-threatening complications because of the proximity of the pectineal ligament to main vessels.

The International Urogynecological Association/International Continence Society classification of complications of prosthesis and graft insertion: Pros and cons and a review of the literature

International Urogynecological Association (IUGA) and the International Continence Society (ICS) and the Joint IUGA/ICS Working Group on Complications Terminology formulated a standardized terminology and classification of complications related to the use of prosthesis in female pelvic floor surgeries. It was mainly purposed to globally standardize the complications and related definitions in order to obtain factual rates and to enable comparisons and surgical audits. Although this unique classification has frequently been cited in the literature, some concerns have been raised against its complexity of use and inter- and intraobserver variability. This review aimed to discuss the rationale behind the IUGA/ICS complication classification system, underline the opposing views, and provide the Turkish version of an online calculator facilitating the universal coding to increase the utility.

McDonald versus modified Shirodkar rescue cerclage in women with prolapsed fetal membranes.

Purpose: We compared the efficacy of modified Shirodkar and McDonald rescue cerclage techniques in women with singleton pregnancies.Methods: The study sample included 47 women who presented at two tertiary hospitals in Turkey from 2008 to 2017 and underwent rescue cerclage due to cervical incompetence and cervical dilatation with fetal membranes prolapsed into the vagina. The outcomes were compared by cerclage technique used, Shirodkar or McDonald.Results: The McDonald cerclage was applied in 27 cases, and modified Shirodkar cerclage in 20 cases. A longer cerclage-to-birth interval (83.8 ± 37.6 vs. 63.7 ± 38.9 days) and later gestational age at delivery (33 vs. 31 weeks) were observed with the Shirodkar cerclage, although these differences were not statistically significant (p = .08 and .63, respectively). Both groups had similar delivery rates after 28, 32, and 37 weeks (p = .20, .15, and .25, respectively), whereas the modified Shirodkar technique resulted in a higher rate of live births although these differences were not statistically significant (85% vs. 63%, p = .09).Conclusion: The effects of the McDonald and modified Shirodkar cerclage procedures on prolonging pregnancy and improving the live birth rate were similar. Therefore, either technique can be applied to prevent neonatal loss due to advanced prematurity.

Sacrospinous Ligament Fixation Under Local Anesthesia in Elderly Patients at High Risk of General Anesthesia.

Introduction and Hypothesis: Sacrospinous ligament fixation(SSLF) is a commonly used surgical procedure in pelvic organ prolapse due to high treatment success rates. Many intraoperative and postoperative anesthesia-related obstacles may be encountered by the elderly population. Local anesthesia alone or with intravenous sedation may provide simple, cheap, and safe anesthesia. For elderly patients at high risk for general anesthesia according to the American Society of Anesthesiologists(ASA), it is better to operate through the vaginal route under local anesthesia. To perform minimal invasive SSLF surgery, the Pelvic Floor Repair Tissue Fixing Anchor, which is a target-specific system, can be used. In this prospective observational study, evaluation was made of elderly patients who underwent SSLF under local anesthesia. Materials and Methods: The study included 11 patients evaluated as high risk for general and regional anesthesia who underwent SSLF under local anesthesia as pelvic organ prolapse surgery. All operations were performed by a single experienced surgeon using 1% lidocaine infiltration and the Pelvic Floor Repair Tissue Fixing Anchor system. Results: The mean age of the patients was 69.6 years. Stage IV prolapse was determined in 7 (63.6%) patients, 4 (36.3%) had a history of hysterectomy, 5 (45.4%) were classified as ASA 3, and 6 (54.6%) as ASA 4. No complications occurred and patients were followed up for 24 months. In two patients, recurrence of POP was observed at postoperative 8 and 10 months, respectively. Conclusions: The results of this study demonstrated the surgical and anesthetic safety of SSLF under local anesthesia for pelvic organ prolapse in elderly patients.