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.

Patients' perceptions toward and the driving factors of decision-making for opportunistic bilateral salpingectomy at the time of cesarean section.

OBJECTIVE: Enough data can be found in the literature regarding the protective effect of tubal ligation on gynecological cancers. In addition, a large body of evidence revealed that prophylactic bilateral salpingectomy had no significant negative effect on the ovarian function, quality of life, sexuality, surgery duration, and cost-effectivity. This study was aimed at exploring the underlying factors that motivate women for either opportunistic bilateral salpingectomy (OBS) or tubal ligation, particularly focusing on their preferences, knowledge, and beliefs toward female sterilization, satisfaction from counseling, and body image following the salpingectomy. MATERIALS AND METHODS: A total of 54 patients who had undergone surgical sterilization with either OBS or tubal ligation were included in this prospective cohort study. The acceptance rate of the OBS at the time of cesarean section among pregnant women seeking surgical sterilization was calculated. The underlying reasons for women's acceptance or refusal for salpingectomy were assessed by a non-validated data collection tool that had 14 open-ended questions focusing on the women's preferences, knowledge, beliefs toward female sterilization, satisfaction from counseling, and body image following the salpingectomy. RESULTS: The acceptance rate of OBS at the time of cesarean section among pregnant women and electively among non-pregnant women were 93.5% (n=43/46) and 75% (6/8), respectively. The main driving factors influencing the decision of preferring OBS over tubal ligation were the risk-reducing effect for ovarian cancer and superior pregnancy prevention. CONCLUSION: The acceptance rate of OBS at the time of cesarean section was found to be very high, and it should therefore be offered at the time of cesarean section to women who desire permanent contraception.

Women's knowledge and beliefs towards vaccination for influenza during pregnancy in Turkey and underlying factors of misinformation: a single-centre cross-sectional study.

OBJECTIVE: The aim of the study was to evaluate the knowledge and perceptions of the pregnant women presenting to our hospital for seasonal vaccination for influenza and to determine the factors associated with it. METHOD: In this cross-sectional study pregnant woman presenting to our hospital between October 2018 and March 2019 were evaluated. A non-validated, well-detailed questionnaire addressing the vaccination rates, participants' perceptions about the facts behind the vaccination for influenza and the factors associated with refusal of vaccination was performed. Women's knowledge level provided by their healthcare providers was also questioned. RESULTS: A total of 250 participants were included in the study. The average age of the patients was 28.85 ± 5.42 years (range 18-43); and the average pregnancy week was 19 ± 9.75. It was determined that 98% (n = 245) of the participants did not have any vaccinations before, and 98.8% (n = 247) did not have any vaccination during their current pregnancy. 65.2% (n = 163) of the participants did not know that the vaccination for influenza was safe in pregnancy; and 64% (n = 160) did not know that the vaccination for influenza was recommended in pregnancy. The most frequent responses given by the participants to justify their refusal for the vaccination was "my doctor was against" and "it can be harmful to my baby" (25.6% and 24%, respectively). It was determined that 98.4% (n = 246) of the participants were not recommended about the vaccination for influenza by any healthcare centres; and 92.8% (n = 232) did not receive any information on vaccination for influenza. CONCLUSION: The knowledge of the participants on vaccination for influenza was inadequate and had misconceptions. The inadequacy of healthcare employees, government institutions and the media may have played roles in this outcome. The reasons underlying the inadequacy of the healthcare providers on vaccination for influenza may be questioned.

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.

Does Suture Material Affect Uterine Scar Healing After Cesarean Section? Results from a Randomized Controlled Trial.

Background: Impaired healing of the uterine scar after cesarean has been associated with adverse gynecological and obstetric outcomes. Although a large number of studies have been conducted on the events leading to this, information obtained from prospective randomized studies examining the role of suture material in the formation of cesarean scar defect (CSD) is lacking. Objective: To evaluate the effects of synthetic suture materials on CSD formation. Study design: We performed a two-arm 1:1 randomized study in women with singleton pregnancies undergoing elective primary cesarean delivery after the 38th week of gestation. Uterine scar closure was performed using synthetic absorbable monofilament and multifilament sutures. The primary outcome was residual myometrial thickness (RMT) in the area of the scar, measured by transvaginal ultrasound 6-9 months after birth. Secondary outcomes included differences in mean operative time, mean estimated blood loss at the time of surgery, and the rates of postoperative gynecological sequelae. Results: Complete follow-up was obtained from 94 (88%) of 107 participants. RMT was thicker in the monofilament compared to the multifilament suture group (5.5 ± 2.24 vs. 4.18 ± 1.76, p = 0.01). Hemoglobin delta was higher in the monofilament suture group (1.59 ± 0.96 vs. 1.25 ± 0.60, p = 0.04). There was no statistically significant difference between the monofilament suture and multifilament suture groups in terms of gynecological sequelae. Conclusion: Closure of the uterine scar with monofilament suture has a positive effect on scar healing and increases RMT thickness.

The Female Genital Self-Image Scale (FGSIS): cross-cultural adaptation and validation of psychometric properties within a Turkish population.

INTRODUCTION AND HYPOTHESIS: Women's perceived satisfaction from their own genital appearance is linked to genital image and sexual esteem. A comprehensive and easy to use scale to measure self-image was scarce in the literature. It was aimed in the present study to complement cross-culturally adapted and validated into Turkish version of the Female Genital Self-Image Scale (FGSIS) and to assess its psychometric properties. METHODS: After cross-cultural adaptation, the Turkish version of the FGSI, Female Sexual Distress Scale-Revised (FSDS-R), and Female Sexual Function Index (FSFI) were administered to 461 female participants. Content/face validity, exploratory, and confirmatory factor analysis, internal consistency, and reliability were appropriately assessed. Predefined and specific hypotheses were formulated for construct validity. RESULTS: Our findings indicated excellent content/face validity, sufficient internal consistency (Cronbach's alpha 0.818), and test-retest reliability [intraclass correlation coefficient (ICC) 0.951]. Construct validity was demonstrated by proving the hypothesis that participants who have performed at least one vaginal/clitoral masturbation for the last month reported significantly higher FGSIS scores compared with those who abstained (Z -6.37, p < 0.001). Factor analyses formed one factor structure. In the proposed two-factor construct, all seven items demonstrated good to high correlations with their subdomains and lower correlations with the other domain, indicating sufficient convergent validity. CONCLUSIONS: The FGSIS was successfully validated for use in the Turkish population. The scale exhibited strong psychometric properties to assess perceived female genital image. It might be reliably used in genital cosmetic surgeries and in a variety of gynecologic conditions.

Cosmetic outcomes of infraumbilical, supraumbilical, and transumbilical entry routes in laparoscopic surgery.

OBJECTIVE: The aim of the present study was to determine which of the umbilical entry routes for intraperitoneal access has a better cosmetic result. MATERIAL AND METHODS: This was a prospective study (Canadian Task Force classification II-1). In total, 105 patients who underwent laparoscopic surgery were included. A vertical or transverse umbilical incision is appropriately made for the trocar to be inserted, and an infraumbilical, supraumbilical, or transumbilical route was preferred for initial intraperitoneal access. Demographic data of patients, body mass indices, entry point of the trocars (infraumbilical-transumbilical-supraumbilical), type of incision (vertical-transverse), duration of the operation, and scar properties at postoperative week 12 were prospectively collected and analyzed. The Vancouver scar scale was used to evaluate the cosmetic results. RESULTS: Cosmetic results did not differ statistically between the transumbilical-infraumbilical-supraumbilical groups. The variables, such as vascularity, height, and total score, of the Vancouver scar scale were significantly higher in patients who had transverse incisions. There was no statistically significant effect of using a Veress needle with the cosmetic results. There was no statistically significant correlation between age, gravida, body mass indices, skin thickness, time of entry, duration of the operation, and cosmetic results in terms of vascularity, height, and total score. CONCLUSION: During laparoscopic surgery, each patient should be assessed individually for the satisfaction of the patient and, thereby, of the surgeon in terms of cosmetic outcomes. Vertical incision offers superior cosmetic effects than transverse incision. Further research is required to define long-term scar-related outcomes of the laparoscopic intraperitoneal access techniques.

Postpartum urinary retention: Evaluation of risk factors.

OBJECTIVE: Postpartum urinary retention means the absence of spontaneous micturition more than 6 hours after birth or when residual volume after urination is less than 150 cc. If neglected, postpartum urinary retention may result in bladder denervation and detrusor muscle weakness requiring intermittent catheterization or permanent micturition dysfunction. Our goal was to identify the possible risk factors for postpartum urinary retention. MATERIALS AND METHODS: Five hundred sixty female subjects were included in this retrospective study. All data obtained including variables such as age, parity, body mass index, duration of labor, prepartum bladder catheterization were compared between female subjects with and without postpartum urinary retention. RESULTS: Among the 560 patients recruited to our study, 124 (22.1%) had postpartum urinary retention. Third stage duration, time from birth to the first void, and number of peripartum micturitions were found to be potential risk factors for postpartum urinary retention. Different than other studies, our study revealed a correlation between peripartum catheterization and postpartum urinary retention. There were no statistically significant differences between patients with and without postpartum urinary retention in terms of other variables. CONCLUSION: In this study, a correlation between peripartum catheterization and postpartum urinary retention was found. There are studies that reported the possible risk factors related to the occurrence of postpartum urinary retention. More studies should be conducted to investigate long-term results with larger populations.

A randomized prospective comparison of the needleless mini-sling "hammock" and "U-shape" configurations for management of stress urinary incontinence: 18 month follow-up results.

OBJECTIVE: To compare the efficacy of needleless mini-sling placed either retropubic (U-shape) or trans-obturator (hammock-shape) to treat stress urinary incontinence. SETTING: One hundred and twenty six women were randomized in a 2:1 ratio to receive hammock-shaped or U-shaped of Contasure-NDL. METHODS: All surgical procedures were performed by one senior surgeon experienced in anti-incontinence surgery with mesh. Cough-stress test was considered for objective outcome. Subjective outcomes consisted of International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), Patient Global Impression of Improvement (PGI-I) and three-item Likert scale to measure satisfaction. Assessments were performed preoperatively and at postoperative 6th, 12th and 18th month. RESULTS: The objective cure rates at postoperative 6th and 12th month were significantly lower in U-shape group compared to hammock-shape group (85.4 vs. 96.4%; p = 0.034) and was comparable with hammock-shape group at 18th month postoperative (90.2 vs. 96.4%, respectively; p = 0.216). The subjective cure rates at postoperative 6th, 12th and 18th month were similar between groups (90.2/90.2/100% vs. 96.4/96.4/96.4%, respectively; p > 0.05). Median of total ICIQ-SF scores was significantly lower in hammock-shaped group (1.62 ± 2.92) compared to U-shape (3.80 ± 2.64) at 18th month (p < 0.001). The rate of patients reported as very satisfied or satisfied to the Likert scale was 90.2% in U-shape group and 96.4% in hammock group. Patients' responses to PGI-I were majorly distributed to "much better" and "very much better" with a mean score of 1.93 ± 2 in U-shape and 1.33 ± 1 in hammock group at 18th month of follow-up (p < 0.001). CONCLUSION: U-shape placement of needleless single-incision mini-sling mimicking the retropubic route did not satisfy in achieving the patient's goal when compared to hammock-shape placement.

A randomized comparison of a single-incision needleless (Contasure-needleless®) mini-sling versus an inside-out transobturator (Contasure-KIM®) mid-urethral sling in women with stress urinary incontinence: 24-month follow-up results.

INTRODUCTION AND HYPOTHESIS: There is a shortage of reliable data on the efficiency of the under-investigated mini-slings to treat stress urinary incontinence (SUI). We aimed to compare the effectiveness of the single-incision needleless mini-sling (SIMS) with the transobturator inside-out mid-urethral sling (TOT). MATERIALS AND METHODS: Two hundred one women with clinically proven SUI were included in this single-center prospective randomized trial. The patients were randomly allocated to the groups. All surgeries were done by the same single surgeon. Examinations were done by one other blinded surgeon. The patients were followed up for 24 months. Objective cure was defined as the absence of SUI and negative cough-stress test. Subjective cure was defined as no stress leakage of urine after surgery in a validated questionnaire. Failure of the surgery was defined as the need for reoperation. Every complaint was categorized by the IUGA/ICS Classification of Prosthesis-related Complications. RESULTS: The objective (85.4% versus 89.9%, p = 0.362) and subjective (87.6% versus 89.9%, p = 0.636) cure rates were similar with the TOT and SIMS at the postoperative month 24, respectively. The mesh exposure ≤ 1 cm rate was 3.4% for both groups, and the mesh exposure > 1 cm rate was 2.2% for both groups. Overall failure rates were 3.4% and 2.2% for the TOT and SIMS group, respectively. No viscus organ perforation was noted. Complications with the SIMS procedure were less painful compared with TOT (p = 0.024). CONCLUSIONS: Single-incision needleless mini-slings exhibited similar cure rates as the trans-obturator mid-urethral slings from both the patient and clinician points of view in 24 months of follow-up. Mini-slings resulted in significantly less postoperative pain than trans-obturator mid-urethral slings.

Discriminating Performance of Early Uterine and Cervical Artery Pulsatility and Resistivity In Pre-Invasive Cervical Lesions.

OBJECTIVES: The aim of the present study was to investigate the diagnostic effectiveness of uterine and cervical vascularity alone or in combination with human papillomavirus (HPV) DNA testing and with cytology. METHODS: Data were prospectively collected from 129 patients in an outpatient clinic of a secondary setting. Routine liquid-based cervical cytology and HPV-DNA testing were obtained. An abnormal result of any of these high-risk types was viewed as positive. Pulsatility (PI) and resistance (RI) indices of uterine (UA) and cervical (CA) arteries were assessed by Doppler sonography. Pathological diagnosis was considered as the gold standard for assessment. Diagnostic efficiency of alone and joint screening of the three indices for discriminating cervical intraepithelial neoplasia (CIN-I) or above from below was assessed. RESULTS: UA-RI and CA-RI were significantly lower in the HPV (+) group than in the controls (p=0.02 and p=0.03, respectively). In subsequent sub-analysis among patients with positive HPV-DNA, UA-PI was significantly higher in the HPV-16 (+) group than in the HPV-18 (+) group (p=0.04). High-risk HPV (Hr-HPV) testing had the highest sensitivity compared with Doppler and cytology (76.5%, 64.7%, and 58.5%, respectively). Combining CA-RI with cytology or Hr-HPV significantly reduced the sensitivity (23.5% and 29.4, respectively) but improved the specificity from 54.4% to 69.8% and 40.9% to 70.7%, respectively. Combining UA-PI with Hr-HPV slightly increased the positive predictivity when compared with testing Hr-HPV alone (36.1% vs. 33.3%). CONCLUSION: The potential of the Doppler indices of UA and CA was doubtful in discriminating CIN-I or above lesions in the early period. In addition, RI of UA and CA differed with regard to the presence of HPV infection, whereas CA-RI differed in high-risk HPV cases.

A new facilitating technique for postpartum hysterectomy at full dilatation: Cervical clamp.

BACKGROUND: Postpartum hysterectomy is a life saving emergency procedure in the management of uncontrollable severe maternal hemorrhage that every obstetrician should be closely acquainted with despite developments in medical and non-surgical interventions for obstetric hemorrhage. It can be difficult to detect the real boundaries of the cervix at full effacement and dilatation in patients who undergo emergency hysterectomy after vaginal delivery. METHODS: Hereby we propose a simple and effective method to ease the operation by placing two atraumatic ring forceps to the anterior and posterior sides of the cervix during the preoperative vaginal examination and leave the two ring forceps while taking the patient into surgery. The boundary of the vagina and cervix will be determined with the help of the ring forceps intraoperatively, which are already placed before the operation. RESULTS: Cervical clamp technique was successfully performed in four cases underwent to emergency postpartum hysterectomy due to uncontrollable postpartum atony. There were no postoperative complication and re-exploration for the persistent hemorrhage. Postoperative FSFI scores of the cases were 26.7, 27.4, 30.3 and 30.7. CONCLUSION: Taking extra vaginal tissue from the lower level of the cervix may be avoided and the last stage of the total hysterectomy may be facilitated by this simple technique with ensuring of bleeding management.

Predictive factors of methotrexate treatment success in ectopic pregnancy: A single-center tertiary study.

OBJECTIVE: It is controversial whether medical or surgical treatment options have more successful results in ectopic pregnancy treatment. Although high pretreatment serum hCG levels have been known to be the most important predictor, the appropriate treatment modality for a specific range of hCG level remains unclear. Furthermore, the variables that make a patient a bad candidate for single-dose methotrexate treatment is unclear. The aim of this study was to identify predictive factors associated with the success of single-dose methotrexate treatment in women with ectopic pregnancy. METHODS: In this retrospective study, 101 women with tubal ectopic pregnancies who had been treated with single-dose methotrexate were selected. The gestational ages, pretreatment hCG values, ectopic mass size, and fluid presence in the abdomen were compared between the groups. RESULTS: The mean age of the patients was 30.6±5.8 (range, 19-42) years, and the gestational age at first injection was 7.0±2.13 (range, 2.3-13.6) weeks. The overall treatment success rate was 77.2% (n=79). The mean duration of hospital stay was 4.21±1.89 days in the successfully treated group and 6.92±2.13 days in the failure group (p<0.05). The rate of treatment failure in patients with abdominal fluid was 37.8%, and it was 12.7% in the non-fluid group (p=0.03). hCG values on days 1, 4, and 7 were significantly higher in the unsuccessful group (3887-2589 mIU/mL, 2814-1287 mIU/mL, and 1119-285 mIU/mL, respectively; p<0.05). The cutoff hCG value, which determined the failure of methotrexate treatment, was found to be 1362 mIU/mL. CONCLUSION: In present study, patients with hCG value <1362 mIU/mL were found to be good candidates for methotrexate treatment. Although not strictly decisional, this hCG threshold level can be used to decide on the likelihood of methotrexate success or failure. Detection of abdominal fluid on ultrasonography also can be assessed as a bad prognostic factor, but size of ectopic mass does not correlate with methotrexate treatment success.

Outcome of Cesarean Myomectomy: Is it a Safe Procedure?

OBJECTIVE: Myomectomy performed during cesarean section is still controversial because of the potential for associated complications, especially with large myomas. Many obstetricians avoid performing cesarean myomectomy procedures because of the risk of uncontrollable hemorrhage. However, the prevalence of pregnant women with myomas is increasing, leading to an increase in the likelihood that physicians will encounter this issue. The aim of this study was to compare outcomes and complications of patients who either had or did not have cesarean myomectomy. METHOD: A total of 361 patients were evaluated in this retrospective study. Patients who had cesarean section with myomectomy and patients had cesarean section without myomectomy were compared with regard to demographics, drop in hemoglobin levels, complications, blood transfusion rates and duration of operation. These parameters were also compared when the diameter of the myoma was larger than 5 cm. Values of p < 0.01 and p < 0.05 were considered statistically significant. RESULTS: While maternal age and gravidity were similar in both groups (p > 0.05), the mean myoma diameter was smaller and the duration of operation was longer in the group who underwent cesarean myomectomy (p < 0.05). The reduction in hemoglobin level, rate of complications, and number of transfusions were similar in both groups (p > 0.05). CONCLUSION: This study shows that myomectomy during cesarean section does not increase complications or transfusion rates and appears to be a safe procedure.

Comparison of uterine, endometrial and ovarian blood flow by transvaginal color Doppler ultrasound in ovulatory and anovulatory cycles.

OBJECTIVES: Blood flow to uterus and ovaries is demonstrated to be altered during mensturation. Studies has been published stating that blood flow differs also in ovulatory and anovulatory cycles. In this study, using color Doppler ultrasound, we aim to compare uterine, endometrial and ovarian blood flow during ovulatory and anovulatory cycles. MATERIAL AND METHODS: Women volunteers who are aged between 18-40 had no endocrinological problem and not recieving exogenous hormone therapy were included to study. Blood levels of FSH, LH, E2, prolactine, DHEAS, free T4 were collected in early follicular phase. Uterina, subendometrial and intraovarian artery blood flow pulsatility and resistance indexes were analysed using Doppler USG technique. Patients were called out to control on 21st of cycle and progesterone levels were analysed. Patients who has ovulation signs in USG and progesterone level above 5 ng/mL were included to ovulatory cycle group. Patient who has no signs of ovulation in ultrasound and has not enough progesterone level were included to anovulatory cycle group. RESULTS: LH and E2 levels were significantly higher in anovulatory patients. No correlation was found between endometrial blood flow resistance and basal E2, prolactine, testosterone levels. However, DHEAS levels were related to endometrial blood flow resistance in anovulatory cycles. No correlation was found between ovarian blood flow resistance/uterine blood flow resistance and basal E2, prolactine, testosterone, DHEAS levels. CONCLUSIONS: There is statistically significant difference between endometrial, ovarian, uterine artery blood flow resistance in ovulatory and anovulatory cycles. Blood flow resistance was found to be increased in anovulatory patients. Increased E2 levels in anovulatory cycles were related to endometrial linethickness and endometrial volume.