Historical perspective of vaginal hysterectomy: the resilience of art and evidence-based medicine in the age of technology.

OBJECTIVE: The aim of this study was to describe, from a historical perspective, the relevance, resilience and outcomes of vaginal hysterectomy (VH) in gynecology in the age of technological scenario. METHODS: The authors searched records from January 2011 to January 2021 on the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library) for combinations of the terms "vaginal hysterectomy," "outcomes" AND "history"; and before that period, if the search had historical relevance. INCLUSION CRITERIA: randomized clinical trials; hysterectomy performed for benign gynecological conditions; and VH outcomes compared with Abdominal Hysterectomy (AH), Laparoscopic Hysterectomy (LH) or Robotic Hysterectomy (RH). RESULTS: The VH combines sequences of reproducible techniques which have been developed over the years to safely and effectively overcome the limitations of difficult cases of vaginal extirpation from the uterus. CONCLUSION: The authors support endoscopic surgical approaches in complex surgery for benign indications, urogynecology, and gynecologic oncology when appropriate. However, what makes the gynecological surgeon different from the general surgeon is the vaginal access. It is essential to continue to train residents in vaginal surgical skills and provide safe and cost-effective patient care. The art of technology is the resilience of keeping only the patient at the center of innovation.

Effectiveness of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an assessor-masked randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to evaluate the effectiveness of adding voluntary pelvic floor muscle contraction (PFMC) to a Pilates exercise program in sedentary nulliparous women. METHODS: Fifty-seven healthy nulliparous and physically inactive women were randomized to a Pilates exercise program (PEP) with or without PFMC. Forty-eight women concluded this study (24 participants for each group). Each woman was evaluated before and after the PEP, by a physiotherapist and an urogynecologist (UG). Neither of the professionals was revealed to them. This physiotherapist measured their pelvic floor muscle strength by using both a perineometer (Peritron) and vaginal palpation (Oxford Scale). The UG, who performed 3D perineal ultrasound examinations, collected their data and evaluated the results for pubovisceral muscle thickness and the levator hiatus area (LA). Both professionals were blinded to the group allocation. The protocol for both groups consisted of 24 bi-weekly 1-h individual sessions of Pilates exercises, developed by another physiotherapist who specializes in PFM rehabilitation and the Pilates technique. RESULTS: The PEP+ PFMC group showed significantly greater strength improvements than the PEP group when comparing the Oxford scale, vaginal pressure and pubovisceral muscle thickness during contraction measurements at baseline and post-treatment. CONCLUSIONS: Our findings suggest that adding a voluntary PFMC to a Pilates exercise program is more effective than Pilates alone in improving PFM strength in sedentary nulliparous women.

Multicenter, randomized trial comparing native vaginal tissue repair and synthetic mesh repair for genital prolapse surgical treatment.

INTRODUCTION AND HYPOTHESIS: This trial aimed to compare the outcomes of native vaginal tissue repair versus polypropylene mesh repair for the treatment of severe genital prolapse. METHODS: This multicenter randomized trial included 184 women, with POP-Q stage 3 or 4. They were randomly assigned to undergo surgical treatment using native tissue repair (n = 90) or synthetic mesh repair (n = 94). Native tissue repair surgery was performed according to site-specific defects, including sacrospinous ligament fixation for apical defects. Mesh repair (Prolift™) was performed in accordance with manufacturer recommendations. Hysterectomy was performed in all cases of uterine prolapse. Statistical tests were used to compare between-group and within-group differences before the surgery and at 1-year follow-up. We considered cure to have occurred when the POP-Q point evaluation was equal to or less than 0 and POP-Q point C better than or equal to half the total vaginal length (TVL) after 1 year. The patients answered the Prolapse Quality-of-Life Questionnaire (PQoL) and the Sexual Quotient Female Version (QS-F) questionnaire. RESULTS: Both groups were homogeneous preoperatively. There were no differences between the groups in operative time, complications or pain. At 1-year follow-up, anatomical cure rates were better in the mesh group in the anterior compartment (p = 0.019). Significant improvement in PQoL scores at 1-year follow up were observed in each group; between-group comparisons of changes in PQoL scores revealed greater improvement in the mesh group. CONCLUSION: Both techniques were effective. Anatomical efficacy was superior in the mesh group regarding the anterior compartment; quality of life changes were also greater in the mesh group. Complications were significantly higher in the mesh group.

Assessing the impact of twin pregnancies on the pelvic floor using 3-dimensional sonography: a pilot study.

OBJECTIVES: The purpose of this study was to compare the morphologic characteristics of the pelvic floor musculature between women with twin and singleton pregnancies. METHODS: We conducted a cross-sectional case-control study of 40 nulliparous women aged 20 to 38 years to compare women with singleton pregnancies (n = 23) to women with twin pregnancies (n = 17). Biometric measurements of the levator hiatus and the sagittal and coronal diameters were made by transperineal 3-dimensional sonography between the 28th and 38th gestational weeks. Comparisons were statistically assessed by the unpaired Student t test and Mann-Whitney U test. RESULTS: For the women with singleton pregnancies, the mean sagittal diameters at rest, during the Valsalva maneuver, and during pelvic floor contraction were 5.3, 5.7, and 4.5 cm, respectively, and the mean coronal diameters under these conditions were 3.8, 4.1, and 3.6 cm. For the women with twin pregnancies, the corresponding values were as follows: mean sagittal diameters, 5.3, 5.8, and 4.6 cm; and mean coronal diameters, 4.3, 4.3, and 3.8 cm. The differences in coronal diameters were statistically significant at rest (P < .01) and during contraction (P = .04). The mean levator hiatal areas for the women with singleton pregnancies were 14.6, 16.9, and 11.7 cm(2) at rest, during Valsalva, and during contraction, respectively; for the women with twin pregnancies, these values were 16.0, 18.6, and 12.6 cm(2). CONCLUSIONS: Hiatal measurements were higher in twin than in singleton pregnancies, with coronal diameters reaching significance at rest and during contraction, suggesting that pelvic support undergoes greater changes during twin pregnancy.