Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications.

Objective: As the second most common surgery performed on women in the United States, hysterectomy techniques are constantly examined for validity and superiority. The vaginal natural orifice transluminal endoscopic surgery (vNOTES) has increased in popularity since the first vNOTES hysterectomy was performed in 2012. We sought out to evaluate the safety and effectiveness of hysterectomy by vNOTES compared to conventional vaginal hysterectomy for various benign indications. Data sources: We searched Scopus, Medline, PubMed, ClinicalTrials.Gov, and the Cochrane Library. Our search included all studies from each respective database's inception until September 1, 2023. Study eligibility criteria: We included eligible studies that compare vNOTES hysterectomy versus conventional vaginal hysterectomy for various benign indications, and included at least one of our preselected outcomes. The main outcomes were estimated blood loss (mL), operation time (min), length of hospital stay (d), Visual Analogue Scale pain score at Day 1, intraoperative complications, and postoperative complications. Study appraisal and synthesis methods: We analyzed data of our continuous outcomes using RevMan 5.4.1. Continuous outcomes were analyzed using mean difference (MD) and 95% confidence intervals (CIs) under the inverse variance analysis method. We assessed the quality of the studies using the ROBINS-I assessment tool. Results: We found 4 eligible studies to include in our analysis. Surgeon declared estimated blood loss was found to be similar in both groups (MD=-44.70 [-99.97, 10.57]; P=.11). Also, the total length of hospital stay (in days) was found to be comparable in both groups (MD=-0.16 [-1.62, 1.30]; P=.83). We also found no other statistically significant difference between hysterectomy by vNOTES and vaginal hysterectomy in other studied outcomes, including the duration of the operation, the Visual Analogue Scale Pain score after 1 day, intraoperative complications, and postoperative complications. Conclusion: vNOTES seems to be associated with a nonsignificant lower surgeon declared estimated blood loss. We found no other significant differences in hospital stay, intraoperative, or postoperative outcomes. Further studies may clarify if other differences in safety or efficacy exist.

Surgical Approach to Urethral Diverticulum and Urethrovaginal Fistula With Mesh Erosion.

INTRODUCTION AND HYPOTHESIS: This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS: We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS: The surgery was accomplished without complications. CONCLUSIONS: To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.

Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery.

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.

Exploring the feasibility of indocyanine green fluorescence for intraoperative ureteral visualisation in robotic transvaginal natural orifice transluminal endoscopy surgery during endometriosis resection.

BACKGROUND: To assess the feasibility of use of indocyanine green (ICG) in identifying and minimising urinary tract injury during surgical resection of endometriosis through robotic transvaginal natural orifice transluminal endoscopy surgery (RvNOTES). METHODS: We conducted a retrospective case series in two academic tertiary care hospitals. We examined 53 patients who underwent RvNOTES hysterectomy with planned endometriosis resection. RESULTS: The study involved 53 patients undergoing RvNOTES with ICG fluorescence for endometriosis resection. Mean patient age was 37.98 ± 6.65 years. Operative time averaged 181.32 ± 53.94 min, with estimated blood loss at 45.57 ± 33.62 mL. Postoperative stay averaged 0.23 ± 0.47 days. No ICG-related complications occurred. CONCLUSION: No complications occurred with ICG fluorescence in RvNOTES. It appears to be a safe option for ureteral localisation and preservation. ICG fluorescence is widely used in diverse medical specialities for identifying ureters during complex surgeries. Larger studies are needed to firmly establish its advantages in intraoperative ureteral visualisation during RvNOTES for deep infiltrative endometriosis.

Ovarian tissue biopsy for cryopreservation by vaginal natural orifice transluminal endoscopic surgery: a new approach for a minimal invasive ovarian biopsy.

OBJECTIVE: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging surgical procedure that combines the advantages of the vaginal approach with laparoscopic vision and instrumentation. Shorter hospitalization and lesser postoperative pain associated with vNOTES may be explained by the advantages of this innovative surgical approach (e.g., absence of abdominal incisions, shorter operative time, and lower insufflation pressure). Ovarian tissue cryopreservation allows to preserve reproductive and endocrine functions in young women with oncological disease at risk of premature ovarian insufficiency (POI) caused by gonadotoxic treatments. Ovarian tissue biopsy for cryopreservation consists of a large biopsy of 1 or both ovaries that is usually performed by laparoscopy. Then, the removed ovarian tissue is cryopreserved for the future transplant after cancer remission. The volume of ovarian biopsy ranges from 50% of the ovary for women at moderate risk of POI to 70%-100% of it for those at high risk. The inclusion criteria for ovarian tissue cryopreservation are women aged <35 years who cannot delay start of oncological treatments for follicle cryopreservation, with a moderate or high risk of POI and good chance of 5-year survival. Ovarian tissue cryopreservation cannot be performed if tumor treatments include uterine irradiation or for tumors at risk of ovarian metastases (as in the case of ovarian cancer, leukemia, neuroblastoma, or Burkitt lymphoma). Despite widespread adoption of vNOTES in gynecology, ovarian biopsy for cryopreservation has never been performed using this route. DESIGN: Step-by-step explanation of the procedure with descriptive text and narrated video footage. SETTING: Tertiary-level referral academic center. PATIENT(S): A 27-year-old patient recently diagnosed with low-grade follicular non-Hodgkin lymphoma was referred to our center for ovarian tissue cryopreservation before chemotherapy. The patient included in this study gave informed consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites. Because of the nature of the study, institutional review board approval was not required. INTERVENTION(S): Access to the peritoneal cavity was created by a 3-cm posterior colpotomy. The peritoneum was then opened using cold scissors and temporarily fixed to the posterior vaginal wall. The GelPOINT Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA), with 1 10-mm and 2 5-mm trocars, was used as the vNOTES port. The inner Alexis ring of the GelPOINT was inserted through the colpotomy into the pouch of Douglas. A hysterometer was placed into the uterine cavity to keep the uterus anteverted during the surgery. A pneumoperitoneum was created to a pressure of 8 mm Hg, and the operating table was tilted to a 20° Trendelenburg position. A 10-mm rigid 30° camera was inserted in the inferior and larger trocar, and both ovaries were visualized. Seventy percent of the left ovary was removed with cold scissors to minimize trauma on the surgical specimen. After removal of the GelPOINT cap, ovarian biopsy was immediately picked up by the biologist of our fertility center. The ovary was coagulated with a bipolar instrument. The hysterometer was then replaced by a uterine manipulator to perform tubal patency test, and blue dye passage through both salpinges was observed. Finally, the Alexis retractor and stich on the posterior peritoneum were removed, and the vagina was sutured using interrupted stiches. The total operative time was 25 minutes. MAIN OUTCOMES MEASURE(S): Ovarian tissue biopsy for cryopreservation by vNOTES. RESULT(S): No intraoperative and postoperative complications were reported, and the patient was discharged after 24 hours from surgery. CONCLUSION(S): Vaginal natural orifice transluminal endoscopic surgery may be a feasible alternative approach to laparoscopy for ovarian tissue cryopreservation: it allows an easy access to the ovaries and removal of different tissue volumes. Patients undergoing ovarian cryopreservation may benefit from the vNOTES approach because a rapid postoperative recovery is crucial to start chemotherapy in a short time. As for other vNOTES procedures, accurate selection of patients seems to be crucial for a successful ovarian tissue cryopreservation. We believe that the inclusion and exclusion criteria reported for other gynecologic procedures performed through vNOTES may also be valid for ovarian tissue cryopreservation by vNOTES. Women at high risk of pelvic adhesions (e.g., coexistent endometriosis, previous pelvic surgery, or inflammatory pelvic disease), those with an increased body mass index or enlarged uterus, and those with cervical, vaginal, or uterine cancer cannot be considered for this approach because all these factors are associated with failure of vNOTES. On the other hand, women with no history of surgery, endometriosis, and large myomas may benefit from the vNOTES approach, and these women represent most of patients who undergo ovarian tissue cryopreservation. Further and larger studies are needed to assess the efficacy and safety of this new approach.

Noncongenital Vaginal Obliteration: Surgical Restoration of Vaginal Patency for GVHD.

STUDY OBJECTIVE: To provide a brief overview of noncongenital causes of vaginal obliteration and stenosis, discuss a unique case of vaginal agglutination in a patient who developed genital graft-versus-host disease (GVHD) after receiving a bone marrow transplant (BMT), and present the steps of a laparoscopic total hysterectomy and lysis of vaginal adhesions that successfully restored vaginal patency without the need for grafting. DESIGN: This video gives an overview of noncongenital causes of vaginal obliteration with a focus on genital GVHD. SETTING: GVHD is a known possible complication of BMT. This condition can lead to vaginal obliteration, affecting sexual performance and quality of life. INTERVENTIONS: We discuss the clinical course of a 54-year-old female with history of acute monocytic leukemia treated with chemotherapy and a BMT. She subsequently developed genital GVHD with complete vaginal obliteration, precluding penetrative intercourse and causing pain, discomfort, and decreased quality of life. We present a combined laparoscopic and vaginal surgical procedure that allowed for the creation of a neovagina with a normal length and caliber. While grafting is sometimes necessary due to inflammation and scarring, we were able to avoid a graft by using a combined laparoscopic and vaginal approach, followed by restoration of continuity between the unaffected upper and lower vaginal tissues. CONCLUSION: GVHD can be quite debilitating for patients. A combined surgical approach is a feasible option for patients with complex pathology not amenable to simple transvaginal adhesiolysis. Surgical restoration of the vagina does not necessarily require the use of a graft if the anatomy is reestablished successfully. VIDEO ABSTRACT.

A retrospective study of the effects of uterine manipulators on prognosis in patients with cervical cancer.

OBJECTIVE: This retrospective study investigated the effects of uterine manipulator use during minimally invasive radical hysterectomy on prognosis in patients with cervical cancer. METHODS: We collected clinical data on 762 patients with stage IA2 to IIB cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy in Chinese PLA General Hospital from 2009 to 2019. Kaplan-Meier analysis and log-rank tests were used to compare the 5-year overall survival rates between patients treated with and without a uterine manipulator. RESULTS: Patient demographics did not differ between the two groups. In addition, the incidence of lymphovascular space invasion, tumor size, pathologic types, the International Federation of Gynecology and Obstetrics stage, the histologic grade, and the rate of lymphatic metastases did not differ between the groups. Meanwhile, perioperative clinical indicators were similar in the groups. Furthermore, no significant differences in 5-year survival rates and survival curves were recorded between the groups among both all patients (84.5% vs. 85.6%) and early-stage patients (89.1% vs. 89.2%). CONCLUSIONS: The use of uterine manipulators during minimally invasive radical hysterectomy for cervical cancer did not affect clinicopathological markers or increase the risk of death.

Two-Year Preclinical Evaluation of Long-Term Absorbable Poly-4-hydroxybutyrate Scaffold for Surgical Correction of Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: Fully absorbable implants may be an alternative to permanent meshes in the correction pf pelvic organ prolapse (POP) as they may reduce adverse events by promoting tissue regeneration and collagen metabolism. This study was aimed at evaluating the long-term host and biomechanical response to a fully absorbable poly-4-hydroxybutyrate (P4HB) scaffold in comparison with polypropylene (PP) mesh. METHODS: Poly-4-hydroxybutyrate scaffold (n = 16) and PP mesh (n = 16) were surgically implanted in the posterior vaginal wall of parous female Dohne Merino sheep. Vaginal explants were evaluated in terms of gross necropsy, host response (immune response, collagen deposition, tissue regeneration), biomechanics, and degradation of P4HB at 12 and 24 months post-implantation. RESULTS: Gross necropsy revealed no infection or fluid collection using P4HB or PP. At 12 months, exposures were observed with both P4HB (3 out of 8) and PP (4 out of 8), whereas at 24 months, exposures were observed only with PP (4 out of 8). The tensile stiffness of the P4HB explants was maintained over time despite complete absorption of P4HB. The collagen amount of the vaginal tissue after P4HB implantation increased over time and was significantly higher than PP at 24 months. P4HB scaffolds exhibited significantly lower myofibroblast differentiation than PP meshes at 24 months. CONCLUSIONS: The P4HB scaffold allowed for gradual load transfer to the vaginal wall and resulted in mechanically self-sufficient tissue. P4HB scaffold had a more favorable host response than PP mesh, with higher collagen content, lower myofibroblastic differentiation, and no exposures at 24 months. P4HB scaffolds have potential as an alternative to permanent implants in treating POP.

Laparoscopic Versus Vaginal Uterosacral Ligament Suspension in Women With Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of the Literature.

OBJECTIVE: Uterosacral ligament suspension (USLS) is one of the most frequently used operations for the restoration of apical support in women with uterovaginal prolapse. However, existing studies are inconclusive as to whether and which surgical access route is superior. The aim of the present meta-analysis is tentatively to compare the efficiency and the postoperative complications of laparoscopic USLS (L-USLS) and vaginal USLS (V-USLS), highlighting that current evidence remains inconclusive regarding the superiority of either surgical access route. DATA SOURCES: We performed a systematic literature review of 5 major databases (Medline, Scopus, Google Scholar Cochrane Central Register of Controlled Trials and Clinicaltrials.gov) from inception till April 2023. METHODS OF STUDY SELECTION: No language restrictions were applied. All comparative studies that compared L-USLS and V-USLS for the management of women with uterovaginal prolapse were included. TABULATION, INTEGRATION, AND RESULTS: Data from 6 retrospective cohort studies on 856 patients were extracted and analyzed. The methodological quality of the included studies was assessed using the risk of bias in nonrandomized studies of interventions tool and ranged between moderate to serious. The pooled results suggest that L-USLS was associated with a potentially decreased incidence of ureteral compromise (odds ratio [OR], 0.19; 95% confidence interval [CI] 0.04-0.89; p = .04) and seemingly lower objective (OR 0.47; 95% CI 0.23-0.97; p = .04) and subjective recurrence rates (OR 0.46; 95% CI 0.23-0.92; p = .03). There were no significant differences between the rates of postoperative pain from USLS sutures, postoperative pelvic hematomas, the suture exposure/granulation tissue formation, and the prolapse recurrence retreatment among the 2 groups. CONCLUSION: The present meta-analysis indicates that L-USLS is possibly associated with significantly fewer ureteral compromise rates and decreased subjective and objective recurrences rates compared to V-USLS. Nevertheless, given the limitations in data quality and heterogeneity of the included studies, these findings should be interpreted with caution. Large-scale randomized studies are essential to more definitively determine the relative merits of the laparoscopic versus vaginal approach.

Evaluation and Resection of a Longitudinal Vaginal Septum in an Adult.

OBJECTIVE: The objective of this video is to demonstrate the diagnosis, evaluation, and techniques for surgical management of a longitudinal vaginal septum, a rare müllerian anomaly. DESIGN: This is a stepwise demonstration of evaluation and surgical techniques with video narration. SETTING: The incidence of müllerian defects, which can include any anomaly in the fallopian tube, uterus, cervix, or vagina, has been estimated to be 2% to 4% [1]; 30% to 40% of patients with müllerian defects also have associated renal anomalies [1,2]. In normal development, the müllerian ducts fuse at 10 weeks' gestation and the septum between the 2 ducts is absorbed in a caudal to cephalad direction [3]. The exact incidence of complete longitudinal vaginal septa is unknown as they are very rare [4]. Longitudinal vaginal septa may cause dyspareunia, inability to have penetrative intercourse, labor dystocia, or hygiene issues and be very emotionally distressing for patients [5]. INTERVENTIONS: Preoperative evaluation of an adult with longitudinal vaginal septum that included a careful physical examination and abdominal and pelvic imaging. Intraoperative resection with key strategies: (1) placing a Foley catheter to help avoid urinary tract injuries and (2) intermittent rectal examinations to retract the rectum away from the plane of dissection. CONCLUSION: Patients who present with longitudinal vaginal septa should undergo evaluation for uterine and renal anomalies. Here, we show that resection of longitudinal vaginal septa in adults is feasible and appropriate for patients who present with inability to have penetrative intercourse. Intraoperatively, care should be taken to avoid injuring the rectum or urinary tract.

Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score.

INTRODUCTION AND HYPOTHESIS: We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model. METHODS: We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic. RESULTS: For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all). CONCLUSIONS: A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Prevention of complications of surgical treatment of stage III-IV cystocele using light polypropylene mesh.

OBJECTIVE: The purpose of study was to report the subjective and objective results of different methods of surgical treatment of cystocele using the transvaginal Mesh-system. METHODOLOGY: A prospective study was conducted from January 2017 to December 2020 comparing anterior colporrhaphy with vaginal mesh and two distinct types of vaginal wall repair sutures in the surgical treatment of cystocele. The primary endpoint was the incidence rate of vaginal wall erosion complications 12 months after surgery. Secondary endpoints were anatomic outcomes, TVM-related morbidity, and patient satisfaction measured using validated questionnaires. RESULTS: In total, 102 patients with stage III-IV cystocele and the average age of 67.2 ± 3.1 years (age range of 47-79 years old) took part in the study. Of the 102 women initially enrolled, 102 (100%) were successfully followed up 12 months after primary surgery. The primary result, the objective erosion development, was radically different in the comparison groups (1.6% against 23.5%, respectively). Analysis of the improved method of operative treatment showed a prominent level of positive, uncomplicated, surgery results of 98.4% (60/61). The anatomic success rate of recovery from cystocele was 99.9% (101/102) 12 months after surgery. CONCLUSION: The suggested method of restoring the anterior vaginal wall in stage III-IV isolated cystocele without signs of incomplete and complete prolapse of the uterus showed a radically positive result. The number of complications was relatively high in the comparison group, but no difference was observed in satisfaction with the anatomical results of the surgery. The percentage of the vaginal wall erosion when using a single-layer suture is 23.5%, when using a two-layer suture is 1.6.

Safety and Efficacy Report for the Use of Poly-4-Hydroxybutyrate as a Retropubic Mid-Urethral Sling (MUS) for Stress Urinary Incontinence: A Prospective 24 Months Follow-Up of New Poly-4-Hydroxybutyrate TephaFlex SUI Bioresorbable MUS.

STUDY OBJECTIVE: To investigate the feasibility and safety of the retropubic mid-urethral sling (MUS) procedure with a resorbable mesh implant made of poly-4-hydroxybutyrate (P4HB). DESIGN: A prospective clinical cohort study with 24 months follow-up. SETTING: A tertiary academic hospital. PATIENTS: Seventeen women with moderate to severe stress urinary incontinence (SUI). INTERVENTIONS: A retropubic MUS procedure with P4HB sling. MEASUREMENTS AND MAIN RESULTS: Seventeen women underwent an uncomplicated MUS procedure with a new sling made of resorbable P4HB. Following safety criteria, there has been no need to stop the study before 24 months' end point. Three serious adverse events were reported during follow-up: (1) inability to void urine after 1 week postsurgery, (2) a hysterectomy and bilateral oophorectomy performed due to a precancerous endometrial lesion at 16 months after initial MUS procedure and (3) exposed mesh with a part of device sheath left behind. These participants underwent an uncomplicated reintervention with no additional and/or permanent harm. Reinterventions because of failure of cure contained 3 second MUS procedures and one admission of urethral bulking agent. Seventy-six percent and 47 percent of patients were objectively cured of SUI at 12 and 24 months, respectively. CONCLUSIONS: Preliminary evidence suggests that a sling made of P4HB can be safely used for MUS procedures and could be an alternative for permanent polypropylene slings in patients that prefer the use of nonpermanent material.

Indigo carmine dye for detecting urinary track damage during vaginal surgery.

OBJECTIVE: Unrecognized ureteral and bladder injury increase morbidity and mortality in gynecologic surgery. The primary objective of this study is to analyze the efficiency of a systematic intra-venous (IV) injection of carmine indigo to detect bladder injury in gynecologic vaginal surgery for benign disease. The secondary objective is to analyze the cost and use of carmine indigo. STUDY DESIGN: A retrospective, monocentric study was conducted in a tertiary hospital between January 2018 and October 2021. All patients undergoing a vaginal surgery of hysterectomy for benign disease or anterior prolapse were systematically included. Patients can be systematically included by the automatic coding of surgery. After anesthesia, during the patient's installation, an intravenous injection of 5 mL of intravenous indigo carmine (Carmyne®) diluted in 100 mL of physiological serum was systematically administered by the anesthesia team. Intraoperative cystoscopy was performed only in cases of suspected associated ureteral injury. RESULTS: We recorded 443 vaginal hysterectomies for benign disease and 95 vaginal anterior prolapse surgeries. There were 6 (1,4%) bladder injuries during vaginal hysterectomies and 1 (1,1%) bladder injury during vaginal prolapse surgery. All bladder injuries were diagnosed intraoperatively. No ureteral injury was diagnosed in this series of patients. No complication related to IV indigo carmine injection was found. In this tertiary hospital, 1085 ampoules of carmine indigo were ordered during the same period, approximatively 270 per year. The total cost to the gynecology and obstetrics department was 19,600 euros, or about 4,900 euros per year. Half of the carmine indigo was used in vaginal surgery and half in laparotomy, caesarean section and endometriosis surgery for suspected bladder or ureteral injury.

Long-term effects of vaginal surgery and endogenous ovarian hormones on the vagina and bladder.

Background: Surgery is a common treatment for pelvic organ prolapse (POP); however, risk of recurrence and reoperation is high, resulting in a negative impact on quality of life and sexual function. Aim: To examine the long-term effects of POP surgery and endogenous circulating ovarian hormones on the vagina and bladder. Methods: Our animal model simulated surgical injury of the vagina and bladder during POP surgery. Female Rowett nude rats were divided into 4 groups: intact control (IC), vaginal surgery only (V), ovariectomy only (O), and ovariectomy + vaginal surgery (OV). Rats were euthanized 10 weeks postsurgery. Proximal vagina and bladder dome/trigone underwent (1) organ bath myography to assess smooth muscle contractility; (2) real-time quantitative polymerase chain reaction to quantify mRNA expression of elastin, collagen I and III, and PGP9.5 (protein gene product 9.5); (3) enzyme-linked immunosorbent assay for protein quantification of elastin and collagen I and III; and (4) hematoxylin-eosin/immunohistochemistry staining. Outcomes: The primary outcome was tissue contractility as measured by organ bath myography. Secondary outcomes included gene and protein expression of collagen I and III and elastin. Results: O and OV showed reduced vaginal wall contractility vs IC and V (P < .002). Bladder dome and trigone displayed different contractile patterns, with significant differences between O and OV (P < .05), suggesting a negative effect from surgery rather than ovariectomy. OV demonstrated consistent reductions in contractility and elastin/collagen protein expression for the vagina and bladder vs IC. V had similar contractility and increased collagen I expression vs IC, suggesting a protective effect of ovarian hormones. Vaginal epithelium thinning was confirmed in the ovariectomized groups (P = .001), although there was no statistical significance in muscularis thinning with surgery or ovariectomy. O, V, and OV showed significant downregulation of PGP9.5 mRNA expression vs IC. Clinical Translation: These data allow researchers to gain insights into the long-term effects of surgery and deprivation of ovarian hormones. Future studies can use this animal model to investigate other mechanisms that may affect long-term tissue changes due to surgical intervention. Strengths and Limitations: Major strengths are long-term data on the effects of POP surgery and development of an animal model for future studies. However, the animal model limits our ability to extrapolate to humans, where tissue healing is modulated by many factors. Conclusion: Our animal model provides evidence that ovarian hormone deprivation and POP surgery result in negative long-term effects on tissue function and extracellular matrix.

Women's Knowledge, Attitudes, and Practice About Female Genital Cosmetic Surgery: A Cross-Sectional Study in Saudi Arabia.

Introduction Vulvoplasty, or female genital cosmetic surgery (FGCS), refers to any surgical alteration of the vaginal or labial anatomy for aesthetic or medical reasons. It aims to restore or enhance the female genitals and can involve multiple procedures such as labiaplasty, clitoral unhooding, monsplasty, vaginoplasty, hymenoplasty, G-spot augmentation, frenuloplasty, perineoplasty, fat injections, or a combination of these. Labiaplasty is currently the most popular procedure among patients. Since the public is exploring FGCS benefits in the media, it can be foreseen that it will soon gain popularity among the population of Saudi Arabia. As a result, the purpose of this study is to assess women's attitudes and knowledge towards genital cosmetic surgeries in Saudi Arabia.  Methods This correlational cross-sectional survey was conducted in Saudi Arabia among women aged 18 years and above, using an online self-structured questionnaire distributed from April 2023 to October 2023. The sample size of 594 respondents was determined based on a minimum requirement of 500 participants, with a confidence level of 95% and a study power of 95%. A convenient sampling method was employed to select participants, and data collection was carried out through a self-administered online questionnaire distributed via various social media platforms. The survey was self-structured, and Cronbach's alpha values for all sections were greater than 0.7. These sections include demographic characteristics, sexual life and obstetric history, and women's knowledge, practices, and attitudes toward FGCS. Descriptive analysis, chi-square test, and t-test were used for data analysis using SPSS software.  Results A total of 589 eligible women were included in the study; 284 (48.2%) were from the central region, and ages ranged from 18 to 65 years, with a mean age of 33.5 years. A total of 401 (68.1%) were married, 366 (62.1%) had a bachelor degree. Two hundred and ninety-one (49.4%) participants heard about FGCS, 165 (28%) knew that it involves surgical procedures to change the appearance of the female genitalia, 144 (24.4%) said it is also known as vaginal rejuvenation or designer vagina surgery and 200 (34%) knew it can involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening, while 190 (32.3%) reported it is sometimes done for aesthetic reasons but may also be done for medical reasons. Only 45 (7.6%) had undergone FGCS, but 112 (19%) confirmed they consider undergoing FGCS for themselves. Four hundred and ninety-eight (84.6%) participants thought that it's important to have access to support services, such as counseling or peer support, 471 (80%) expressed that it's important that healthcare providers in Saudi Arabia are knowledgeable about FGCS, 425 (72.2%) were concerned about the potential risks and complications of FGCS. Conclusion In conclusion, the current study revealed that nearly one out of five women were knowledgeable about FGCS, mainly about the nature and types of the procedure. Higher knowledge levels about FGCS were associated with younger age, higher educational levels, and women who were more likely to consider undergoing FGCS in the future.

Role of Magnetic Resonance Imaging in Pelvic Organ Prolapse Evaluation.

Background and Objectives: The primary method for assessing pelvic floor defects is through physical examination. Magnetic resonance imaging (MRI) is a radiological technique that is useful for identifying the underlying defects of pelvic floor structures that require surgery. The primary aim of this study was to find correspondence between the clinical and radiological staging of pelvic organ prolapse (POP) before and after vaginal surgery. A secondary endpoint was to investigate, through clinical and MRI findings, whether surgery influences continence mechanisms. Finally, we reported changes in the quality of life of women who underwent surgery for prolapse. Materials and Methods: Twenty-five women with prolapse stage ≥ 2 POP-Q were recruited in this prospective study. They underwent preoperative clinical examination, MRI at rest and under the Valsalva maneuver, and quality of life questionnaires. Three months after vaginal surgery, they repeated clinical and radiological evaluation. Results: Twenty women completed the study. Both clinical and MRI evaluations showed an improvement in prolapse and symptoms after surgery. There were some discrepancies between clinical and radiological staging. MRI parameters did not show differences between pre- and postoperative values at rest; under the Valsalva maneuver, instead, the measurements changed after surgery. Continence was not worsened by the widening of the vesicourethral angle. Patients reported an improvement in quality of life. Conclusions: MRI is an accurate and objective method for defining the stage of prolapse, but clinical evaluation alone is sufficient for staging prolapse before surgery and evaluating the result at follow-up. It is an accurate method for visualizing some pelvic structures that can be compromised because of pelvic organ prolapse. MRI showed that vaginal surgery does not affect continence mechanisms.

Anterior vaginal cyst mimicking pelvic organ prolapse: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Large Anterior vaginal cysts can manifest as symptomatic genital prolapse, posing a diagnostic challenge due to their uncommon clinical presentation. CASE PRESENTATION: A 22-year-old primiparous woman with no previous medical history is admitted for delivery. Examination revealed a cystic mass on the anterior vaginal wall. Perineal ultrasound confirmed an independent cyst measuring 45x40x35 mm. The cyst was successfully aspirated, and the patient delivered without complications. At 12 months, the cyst reappeared, requiring vaginal surgical excision. Histological examination identified a Gartner cyst. During follow-up at 6 and 12 months, the patient remained asymptomatic. CLINICAL DISCUSSION: Vaginal cysts typically present as small, solitary, and symptomless. However, they can grow in size, mimicking other conditions and often being misdiagnosed as cystoceles. Consequently, surgical excision of the vaginal cysts is the preferred treatment option, yielding positive anatomical outcomes and high patient satisfaction levels. CONCLUSIONS: In this report, we describe a rare case of a Gartner cyst found on the anterior vaginal wall. The report also underscores the crucial role of imaging in accurately identifying the cyst's location, assessing its association with adjacent tissues, and guiding the surgeon in devising an effective operative plan.

Vaginal Approach to Cesarean Section Scar Pregnancies: A Standardized Ten-step Surgical Procedure.

OBJECTIVE: To show a 10-step standardized vaginal surgical technique to treat first-trimester cesarean section scar pregnancies. DESIGN: A video article with a stepwise demonstration captured in an operation room of a tertiary medical center of a low-income country (Bolivia). SETTING: Cesarean section scar pregnancies have a wide variety of management options. We present a vaginal surgical approach that has been developed by our group with no observed complications in 6 consecutive cases at the time of this publication. INTERVENTIONS: A 10-step technique: (1) patient positioning, (2) cervical exposure and traction, (3) cervical infiltration with vasoconstrictor solution, (4) anterior mucosal incision and dissection of vesicovaginal space, (5) identification of vascular pedicle and ligation, (6) cold-knife isthmocele incision and ectopic pregnancy evacuation, (7) uterine cavity curettage, (8) hysterorrhaphy with interrupted suture, (9) cystoscopy, and (10) vaginal mucosa closure with running suture. We have used this technique in 6 consecutive patients. Operating time ranged between 20 and 25 minutes. All patients were discharged in postoperative day 1. CONCLUSION: We prefer surgical options for these patients because it provides both a complete removal of the ectopic pregnancy and repair of the isthmocele. A vaginal approach to such cases has proven to be a safe, simple, and fully reproductible technique. We find it applicable for any patient with this pathology but especially suitable for low-resource or somehow financially challenged hospitals.

POSTOPERATIVE INFECTIONS AFTER GYNECOLOGICAL SURGERIES IN UKRAINE.

OBJECTIVE: Aim: To determine the current prevalence of surgical site infections (SSIs) after gynecological surgeries and antimicrobial resistance of causing pathogens in Ukraine. PATIENTS AND METHODS: Materials and Methods: Multicenter prospective observational cohort study was conducted from January 2020 to December 2022 in nine hospitals from eight regions of Ukraine. Definitions of HAIs were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Antibiotic susceptibility was done by the disc diffusion test as recommended by EUCAST. RESULTS: Results: A total 12.2% (420/3450) patients who undergoing gynecological surgeries were found to have SSIs. The difference in SSI rates between the three subgroups by route of surgery was not statistically significant, being 12.0% for the abdominal group,11.1% for the vaginal group, and 12.5% for the combined group. The most common causing pathogens of SSIs was Escherichia coli, Pseudomonas aeruginosa, Enterobacter spp., Streptococcus spp., and Klebsiella pneumoniae. Many Gram-negative pathogens isolated from SSI cases were found to be multidrug resistant. CONCLUSION: Conclusions: This study showed that SSIs remains the common complication after gynecological procedures in Ukraine. Best practices should be established and followed to reduce the risk of SSIs associated with gynecologic surgery. Optimizing the antibiotic prophylaxis and empirical antimicrobial therapy may reduce the burden of SSIs in gynecological surgeries, but prevention is the key element.