Comparison of the Effects of Sevoflurane and Desflurane on Endothelial Glycocalyx in Patients Undergoing Laparoscopic Hysterectomy: A Randomized, Double-Blind Trial.

Objective: Various enzymes, reactive oxygen species, inflammatory conditions, and major surgeries cause endothelial glycocalyx breakdown. Inhalation of anaesthetic agents may have protective effects on the endothelium. This study compared syndecan-1 and heparan sulfate levels to evaluate the effects of sevoflurane and desflurane on the endothelial glycocalyx. Methods: This prospective randomized, double-blind study included 46 patients undergoing laparoscopic hysterectomy. The participants were allocated into sevoflurane and desflurane groups. Subsequently, blood samples were drawn at three time points: before anaesthesia induction for a baseline value (T0), after pneumoperitoneum (T1), and after extubation (T2). Heparan sulfate and syndecan-1 levels were measured. Results: There was no statistical difference between the sevoflurane and desflurane groups in terms of heparan sulfate and syndecan-1 levels at any time point. A significant difference was found only in the desflurane group in the intragroup comparisons of the measurements of heparan sulfate levels (χ2=29.826, P < 0.001). Matched pairs of the time points in the desflurane group showed that P=0.036 (Z=-2.099) for T1-T0, P < 0.001 (Z=-3.924) for T2-T0, and P < 0.001 (Z=-4.197) for T2-T1. The change in percentage between T2 and T1 of heparan sulfate in the desflurane group was found to be statistically significant (P=0.034). Conclusion: The damage caused by surgical stress on the endothelial glycocalyx can be reduced by both desflurane and sevoflurane. The protective effect of desflurane is more prominent than that of sevoflurane.

Tocilizumab is effective in preventing ovarian injury induced by ischemia- reperfusion in rats.

Ovarian torsion can be defined as the bending of the ovaries on the supporting ligament, disrupting both venous and arterial blood circulation. Insufficient blood flow causes ovarian tissue hypoxia and leads to ischemia. This study aimed to investigate whether tocilizumab has a protective effect on ischemia-reperfusion injury due to ovarian torsion in rats. Eighteen female Wistar albino rats were divided into three equal groups (Sham (SG), ischemia-reperfusion (OIR), and ischemia-reperfusion+tocilizumab (OIRT)). Degeneration, necrosis, vascular dilatation/congestion, interstitial edema, hemorrhage, and polymorphonuclear lymphocyte (PMNL) infiltration scores were significantly different between the groups (p=0.001 for all parameters). Moreover, the OIRT group had a significant improvement in these criteria compared to the OIR group (p<0.05). Additionally, there was a considerable difference between OIRT and OIR groups in the number of primordial, developing, and atretic follicles groups (p<0.05), while there was no difference in the number of corpus luteum (p=0.052). Stress markers or cytokines, such as MDA, tGSH, NF-κB, TNF-α, IL-1ß, and IL-6, were significantly different between groups (p<0.05). Furthermore, a significant improvement was found in the measured variables when the OIRT group was compared with the OIR group (p<0.05). Tocilizumab may be an alternative option for treating ischemia-reperfusion injury due to ovarian torsion.

Evaluation of abdominal computed tomography findings in patients with COVID-19: a multicenter study

PURPOSE: To evaluate the frequency of abdominal computed tomography (CT) findings in patients with coronavirus disease-2019 (COVID-19) and interrogate the relationship between abdominal CT findings and patient demographic features, clinical findings, and laboratory test results as well as the CT atherosclerosis score in the abdominal aorta. METHODS: This study was designed as a multicenter retrospective study. The abdominal CT findings of 1.181 patients with positive abdominal symptoms from 26 tertiary medical centers with a positive polymerase chain-reaction test for severe acute respiratory syndrome coronavirus 2 were reviewed. The frequency of ischemic and non-ischemic CT findings as well as the association between CT findings, clinical features, and abdominal aortic calcific atherosclerosis score (AA-CAS) were recorded. RESULTS: Ischemic and non-ischemic abdominal CT findings were detected in 240 (20.3%) and 328 (27.7%) patients, respectively. In 147 patients (12.4%), intra-abdominal malignancy was present. The most frequent ischemic abdominal CT findings were bowel wall thickening (n = 120; 10.2%) and perivascular infiltration (n = 40; 3.4%). As for non-ischemic findings, colitis (n = 91; 7.7%) and small bowel inflammation (n = 73; 6.2%) constituted the most frequent disease processes. The duration of hospital stay was found to be higher in patients with abdominal CT findings than in patients without any positive findings (13.8 ± 13 vs. 10.4 ± 12.8 days, P < 0.001). The frequency of abdominal CT findings was significantly higher in patients who did not survive the infection than in patients who were discharged after recovery (41.7% vs. 27.4%, P < 0.001). Increased AA-CAS was found to be associated with a higher risk of ischemic conditions in abdominal CT examinations. CONCLUSION: Abdominal symptoms in patients with COVID-19 are usually associated with positive CT findings. The presence of ischemic findings on CT correlates with poor COVID-19 outcomes. A high AA-CAS is associated with abdominal ischemic findings in patients with COVID-19.

TQ-Ox, a novel synthetic derivative of thymoquinone on ovarian cancer cells in vitro.

There are many studies in the literature on thymoquinone (TQ)-related cancer cells and models, and there is no relevant study investigating the efficacy of the oxime derivative of TQ (TQ-Ox). This study synthesized TQ-Ox and examined its cytotoxic, genotoxic and apoptotic properties in ovarian cancer cells. The structure TQ-Ox was confirmed with NMR. The cytotoxicity by luminometric ATP, intracellular reactive oxygen species (iROS) by fluorometric, intracellular calcium (iCa2+) by fluorometric, mitochondrial membrane potential (MMP) by flow cytometry, glutathione (GSH) levels with GSH/GSSG-Glo assay, DNA damage by comet assay, and apoptosis by acridine orange/ethidium bromide dye were determined. Concentrations of TQ-Ox were statistically increased cytotoxicity, DNA damage, apoptosis, iROS, and iCa2+ in a concentration-dependent manner (p < 0.001). Besides, MMP and GSH levels also decreased statistically significantly (p < 0.001) with increasing concentrations. TQ-Ox would be an effective treatment option by increasing cytotoxicity, genotoxicity, and apoptosis in ovarian carcinoma.

Pleth Variability Index Guided Volume Optimisation in Major Gynaecologic Surgery.

OBJECTIVE: To compare conventional fluid management (CFM) with pleth variability index (PVI) guided goal-directed fluid management (GDFM) during elective total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO) operations. STUDY DESIGN: Randomised controlled trial. PLACE AND DURATION OF STUDY: Department of Anaesthesiology and Reanimation, Faculty of Medicine, Health Sciences University, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, from February to July 2021. METHODOLOGY: This trial included 78 patients aged 18-65 years with ASA I-III who would undergo elective TAH-BSO under general anaesthesia. Following randomisation with the closed envelope method, standard monitoring, and 250 ml crystalloid infusion during anaesthesia induction, maintenance fluid therapy was administered at 8-10 ml/Kg/hour to the control group and 2-3 ml/Kg/hour to the PVI group. If the mean arterial pressure (MAP) was ≤65 mmHg and/or the MAP was decreased by more than 20%, and the PVI was >13%, a 250 ml colloid bolus was given. When there was no response, a vasoactive agent was administered. Vital signs, laboratory findings, and postoperative complications were evaluated. RESULTS: Age, weight, BMI, urine output, bleeding, hospital stay, comorbidities, intraoperative use of blood products, and complication rates were not significantly different between the PVI and CFM groups (p>0.05). The PVI group had shorter operational times and used less crystalloid than the control group (p=0.033 and p<0.001, respectively). The PVI group's postoperative base excess (BE) levels changed significantly less than the control group's (p<0.001). In both pre- and postoperative haemoglobin, haematocrit, urea, creatinine, electrolytes, and lactate measurements, there were no statistically significant differences between the groups (p>0.05). CONCLUSION: PVI-GDFM is equally safe as CFM for intraoperative fluid management during elective complete abdominal hysterectomy and bilateral salpingo-oophorectomy procedures. KEY WORDS: Pleth variability index, Fluid management, Base excess.

Comparison of Isolated Sciatic Nerve and Sacral Nerve Root Endometriosis: A Review of the Literature.

OBJECTIVE: This review aimed to compare isolated sciatic and sacral nerve root endometriosis in terms of anatomic distribution, patients' symptoms and history, diagnostics, treatments, and outcomes. DATA SOURCE: We searched PubMed, MEDLINE, Web of Science, and Embase from inception to October 2021 using a combination of keywords including "sciatic nerve endometriosis," "sacral nerve root endometriosis," and associated Medical Subject Headings. Relevant publications and references were also checked for further articles. METHODS OF STUDY SELECTION: Two independent researchers performed the study selection. We included all original research articles, case reports, and case series in English that reported on the isolated sciatic nerve and sacral nerve root endometriosis. TABULATION, INTEGRATION, AND RESULTS: The initial search identified 92 articles, and 40 articles, mostly case reports and case series, were included. The review included 362 patients: with 256 and 106 patients in the sacral and the sciatic groups, respectively. In both groups, most patients had right-sided endometriosis. In the sciatic group, most of the patients presented with foot drop, leg motor weakness, and sciatic dermatome hypoesthesia. The frequencies of all these symptoms were significantly higher in the sciatic group (all p <.001). By contrast, in the sacral group, most of patients presented with pudendal neuralgia (p <.001). Intraoperative, early, late, and 1-year postoperative complications did not differ significantly between the 2 groups. CONCLUSION: This study indicated that isolated sciatic and sacral nerve root endometrioses were more common on the right side. Laparoscopic surgery was more commonly performed over traditional open or transgluteal surgery techniques. Sacral nerve root endometriosis is often accompanied by deep infiltrating endometriosis. Magnetic resonance imaging and myelography may be useful diagnostic tools in the preoperative workup. There was usually no significant improvement after surgery in cases of isolated sciatic nerve endometriosis presenting with foot drop.

Transvaginal pudendal nerve blocks in patients with pudendal neuralgia: 2-year follow-up results.

PURPOSE: Pudendal neuralgia (PN) is an extremely painful neuropathy of the pudendal nerve resulting in a negative impact on a patient's quality of life. The aim of this study is to evaluate the 2-year outcomes of repetitive doses of the transvaginal pudendal nerve injections (PNI), and to compare the success of the PNI concerning anatomical levels (endopelvic and extrapelvic portion) of the pudendal nerve pathology. METHODS: This retrospective longitudinal cohort study consists of patients with PN diagnosed with the first four essential Nantes criteria. Diagnostic PNI was performed on 67 patients to fulfill the fifth criteria of Nantes. A total of 56 patients who responded to the initial diagnostic PNI underwent therapeutic repeated transvaginal PNIs twice for 3 weeks apart. Mean pain intensity scores were measured using a visual analog scale at the 1st, 3rd, 6th, 12th, and 24th months after the therapeutic blocks were completed. Effectiveness of the PNIs' was defined as ≥ 50% improvement of the initial pain, and relative improvement was defined as 30-50% improvement of the initial pain. Treatment failure was defined as the reduction of the initial pain by less than 30% or the return of the pain to its worst condition. RESULTS: The efficacy of the PNIs significantly declined over time. Pudendal nerve blocks provided a significant decrease in pain scores; however, this decrease lost its strength significantly in the 24th month. The intervention was more effective in entrapments of the pudendal nerve between sacrospinous and sacrotuberous ligaments or below (Level-2) when compared to the injuries in the endopelvic part (Level-1). More than 50% pain reduction continued in five patients with pathology at Level-1 and 24 patients with pathology at Level-2. CONCLUSION: Repeated PNIs could provide a significant decrease in pain scores for both short- and long-term periods. However, the efficacy of the PNIs declined over 2 years. The success of PNIs may be affected by the anatomical level of the nerve injury; therefore, interligamentous pudendal nerve entrapment cases have more benefits than the cases of pudendal nerve entrapment in the endopelvic part. However, it is recommended to perform therapeutic nerve blocks even in patients with suspected endopelvic pudendal nerve pathology before the referral to surgery.

A New and Alternative Route: Transvaginal Natural Orifice Transluminal Endoscopic Scarless Surgery (vaginal natural orifice transluminal endoscopic surgery) For Class 2 and Class 3 Obese Patients Suffering From Benign and Malignant Gynecologic Pathologies.

Background. This study was conducted to investigate the effectiveness of vaginal natural orifice transluminal endoscopic surgery (vNOTES) gynecologic scarless surgery in benign and malignant class 2 and class 3 obese patients. Materials and methods. The class 2 and class 3 obese women undergoing vNOTES scarless surgery for benign and malign indications at a tertiary referral medical center between January 2019 and April 2021 were retrospectively analyzed and surgical outcomes were measured. Results. In this study, 81 class 2 and class 3 obese patients underwent gynecological procedures using vNOTES scarless surgery. Of the 81 operations, 55 of the class 2 obese patients with benign pathologies, and 26 of the class 3 obese patients had malign pathologies. No conversion to conventional laparoscopy or even laparotomy was needed in any of the procedures. All of the surgeries were performed by the same surgeon (Prof. Dr Ahmet Kale). vNOTES scarless surgery was performed on 26 class 3 obese patients with malign pathologies. Of the 26 class 3 obese patients, 22 of the class 3 obese patients with early-stage endometrial carcinoma had very high mean body mass index 41.5 kg/m2 (range 20.6-56) and 4 of the class 3 obese patients had ascites with unknown cause and diagnosed with peritoneal carcinomatosis. The mean postoperative pain VAS scores of class 2 obese patients undergoing vNOTES scarless surgery with benign pathology at 6, 12, and 24 h were 3.19, 1.11, and .66, respectively, and the mean postoperative pain VAS scores of class 3 obese patients underwent vNOTES scarless surgery with malign pathology at 6, 12, and 24 h were 3.30, 1.76, and 1.03, respectively. Conclusion. vNOTES scarless surgery is an alternative surgical method for diagnosis and treatment not only in benign obese cases, but also in severely obese patients with early stage endometrial cancer and patients had with ascites with unknown cause. In the near future, vNOTES scarless surgery will become more preferable by experienced surgeons in benign and malignant obese cases as it has increased satisfaction with esthetic results such as less pain, and improved postoperative quality of life in the short and long term.

Hearing test results of newborns born from the coronavirus disease 2019 (COVID-19) infected mothers: A tertiary center experience in Turkey.

OBJECTIVE: Congenital infections can cause newborn hearing loss. Although vertical transmission of coronavirus disease 2019 (COVID-19) infection is theoretically possible, this has not been proven yet. To our knowledge, there is no previous report on whether COVID-19 infection during pregnancy can cause congenital hearing loss. This paper aimed to find an answer to this question. METHOD: This retrospective, single-center study was performed between April 2020 and May 2021 at a tertiary care referral center in Turkey. A total of 422 pregnant women who had coronavirus infection during pregnancy were followed and 203 of them gave birth in our institution. Results of hearing screening tests of 199 newborns were assessed retrospectively. RESULTS: Of patients included in the study, 23 (11.6%) had the disease in the first trimester, 62 (31.2%) in the second trimester, and 114 (57.3%) in the third trimester. In the first hearing test performed on newborns, unilateral hearing loss was observed in 21 babies (10.5%). Hearing tests of these newborns were found to be normal in the second test performed 15 days later. CONCLUSION: Considering the incidence of congenital hearing loss, the absence of hearing loss in our newborn population does not confirm the argument that coronavirus infection does not cause congenital hearing loss. This issue should be evaluated with larger patient series. In addition, it should be kept in mind that hearing loss can occur at later ages as well.

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Noncatamenial Symptoms.

OBJECTIVE: This review aimed to categorize thoracic endometriosis syndrome (TES) according to whether the presenting symptoms were catamenial and to evaluate whether such a categorization enables a better management strategy. DATA SOURCES: An electronic search was conducted using the PubMed/Medline database. METHODS OF STUDY SELECTION: The following keywords were used in combination with the Boolean operators AND OR: "thoracic endometriosis syndrome," "thoracic endometriosis," "diaphragm endometriosis," and "catamenial pneumothorax." TABULATION, INTEGRATION, AND RESULTS: The initial search yielded 445 articles. Articles in non-English languages, those whose full texts were unavailable, and those that did not present the symptomatology clearly were further excluded. After these exclusions, the review included 240 articles and 480 patients: 61 patients in the noncatamenial group and 419 patients in the catamenial group. The groups differed significantly in presenting symptoms, surgical treatment techniques, and observed localization of endometriotic loci (p <.05). CONCLUSION: This review points out the significant differences between patients with TES with catamenial and noncatamenial symptoms. Such categorization and awareness by clinicians of these differences among patients with TES can be helpful in designing a management strategy. When constructing management guidelines, these differences between patients with catamenial and noncatamenial symptoms should be taken into consideration.

Is it safe to perform elective gynaecologic surgery during the two peaks of COVID-19 pandemic?

PURPOSE: In December 2019, the COVID-19 pandemic started in China and spread around the World. Operations were postponed in most surgical clinics to reduce the risk of contamination and increase the number of beds available in hospitals. We investigate whether elective gynaecologic surgery is safe or not under safety measures. METHODS: A total of 765 patients were operated on electively between 15 March and 30 October 2020 at our inpatient gynaecology clinic. We took the SARS-CoV-2 Reverse Transcriptase (RT) Polymerase Chain Reaction (PCR) test of the nasopharyngeal swab before and after the surgery. Patients were questioned for COVID-19 symptoms by phone calls on the 7th, 15th, 30th and 60th days postoperatively. RESULTS: The average age of patients was 45.6 ± 11(19-81). Sixty-two (8.1%) operations were performed due to gynaecologic malignancies. Three patients (0.39%) were detected as SARS-CoV-2 RT PCR positive within 7 days after surgery. The patients did not need ICU admission or any further treatments. CONCLUSION: Our study offers a novel perspective on elective surgery during a pandemic. The risk assessment of patients should be meticulously done and substantiated on objective variables. According to our study, in a carefully selected patient population, operating under appropriate precautions, elective gynaecologic surgical procedures during the two peaks of the COVID-19 pandemic do not pose a risk to the patients.

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery versus single-port laparoscopy: Comparison of early outcomes.

AIM: The study objective was to compare intraoperative and early postoperative outcomes among patients who underwent hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (and single-port lararoscopy for presumed benign gynecologic disorders). METHODS: We retrospectively reviewed 40 patients who underwent single-port laparoscopic hysterectomy and 20 patients who underwent hysterectomy via natural orifice transluminal endoscopic surgery. Patients' age, body mass index, history of previous delivery and surgery, total operation time (from skin incision to closure), intraoperative and postoperative complications conversion to another surgical procedure, drop of hemoglobin level, postoperative pain at 1 and 18 h, average hospital stay, and clinical outcomes were analyzed. RESULTS: Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery was superior to single-port hysterectomy concerning the length of hospitalization (p < 0.001) and visual analog scale at 1 h (p = 0.024) and 18 h (p < 0.001). In transvaginal natural orifice transluminal endoscopic group, postoperative complications were lower than single-port laparoscopy group (p = 0.023). In transvaginal natural orifice transluminal endoscopy, group conversion to a standard vaginal hysterectomy occurred in two cases (10%). Four patients in the single-port laparoscopic hysterectomy group had umbilical herniation, three had port-site infections, and two patients had vaginal cuff hematoma. These patients required rehospitalization. CONCLUSIONS: Despite hysterectomy via transvaginal natural orifice transluminal surgery has not yet found its place in routine practice in gynecology departments, it could be a prominent alternative approach to other minimally invasive surgical procedures in selected patients with many advantages including lesser pain and lower complication rates compared with single-port laparoscopic hysterectomy.

Laparoscopic Pectopexy: An Effective Procedure for Pelvic Organ Prolapse with an Evident Improvement on Quality of Life.

It has been stated that the effectiveness of pectopexy method for the treatment of pelvic organ prolapse (POP) is similar to sacrocolpopexy. We aimed to search the effects of pectopexy method to the quality of life, sexual function and urinary incontinence. Thirty-one patients who were operated for POP with the technique of laparoscopic pectouteropexy/pectocolpopexy between January 2016 and November 2017 were included the study. Exclusion criteria were pelvic inflammatory disease, suspect of malignancy, pregnancy, prior POP or continence surgery. Quality of life inventories were (P-QOL, PISQ-12, UDI-6, IIQ-7) recorded preoperatively and at the postoperative third month. Results were compared statistically. The percentage of patients with menopause was 67.7% (n=21) and with reproductive term was 32.3% (n=10). Mean prolapse related quality of life inventory (P-QOL) score was 83.45 ± 8.7 (64-98) preoperatively and 8.61 ± 6.4 (0-23) postoperatively (p<0.05). The preoperative and postoperative score of quality of life inventories for urinary symptoms were 20 (15-21) and 2 (0-9) for IIQ-7 and 13 (3-18) and 4 (0-11) for UDI-6, respectively (p<0.05). The mean PISQ-12 sexual quality of life inventory score was 29.61 ± 4.8 (14-38) preoperatively and 7.1 ± 3.2 (1-13) postoperatively. According to our results laparoscopic pectopexy offers a feasible, safe and comfortable alternative for apical prolapse surgery.

The incidence of unexpected gynaecological malignancies in hysterectomies carried out for benign indications.

The aim of the present study was to determine the incidence of unexpected gynaecological malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics. Data from 6448 cases who had undergone hysterectomy for benign indications between the dates of 01.01.2008-01.01.2018 were recorded retrospectively from the database of the institution. The mean age of the cases with malignancy was 59.2 ± 9.66 (45-80) and 76,31% were (29/38) postmenopausal. The mean gravidity was 3.94 ± 1.73 and parity was 3.31 ± 1.45. Their mean BMI was 29.6 ± 4.26 kg/m2 (22.4-41.9 kg/m2 range). These patients were followed for a mean duration of 60.68 ± 37.66 months and during this period death associated with malignancy occurred in 4/38 (%10.52) cases, all of whom had leiomyosarcoma. The benign indications of procedure were as follows: myoma uteri (2675, 41.48%), abnormal uterine bleeding (1508, 23.38%), uterine prolapsus (793, 12.29%), ovarian cyst (619, 9.59%), endometriosis (303, 4.69%), endometrial polyp (264, 4.09%), pelvic pain (238, 3.69%) and other benign causes (48, 0.74%). Unexpected gynaecological malignancy was found in 20 cases (0.31%) with endometrial cancer, in eight cases (0.12%) with uterine sarcoma, in seven cases (0.10%) with ovarian cancer, in one case (0.01%) with tubal cancer and in two (0.03%) with cervical cancer. Gynaecological malignancy was found in 38 of 6648 cases who underwent hysterectomy for benign indications, yielding an incidence rate of 0.58%.IMPACT STATEMENTWhat is already known on this subject? Hysterectomy is the most common gynaecological surgery in the world and although most are performed for benign indications, unexpected gynaecological malignancy is possible in the final pathology results.Although there are available publications investigating unexpected gynaecological malignancy incidences after hysterectomies for benign reasons, the incidence is still not clear. We aimed to contribute to the existing literature with this study, which includes a large number of cases.What do the results of this study add? Our study adds new findings to the body of the knowledge on the incidence of unexpected gynaecological malignancies in hysterectomies for benign indications. Gynaecological malignancy was found in 38 of 6648 cases who underwent hysterectomy for benign indications, yielding an incidence rate of 0.58%.What are the implications of these findings for clinical practice and/or further research? There is an unexpected possibility of gynaecological malignancy even in cases where it is expected to be benign with current diagnostic methods. In cases that are expected to be benign, detailed preoperative evaluation should be performed in all patients to prevent unexpected gynaecological malignancies. More sensitive screening methods should be developed especially in the preoperative differential diagnosis of leiomyoma and leiomyosarcoma.

Intrapelvic Nerve Entrapment Syndrome Caused by a Variation of the Intrapelvic Piriformis Muscle and Abnormal Varicose Vessels: A Case Report.

Entrapment neuropathy of the sciatic nerve and pudendal nerve are painful syndromes that are often overlooked by physicians. Laparoscopic surgical interventions for nerve entrapment syndromes of the posterior pelvis focus on removing the compression lesion with the purpose of eliminating the suspected cause of sciatica, as well as pudendal neuralgia. Herein, the authors report the rare event of sciatic and pudendal nerve entrapment, which was caused by aberrant vessels and a variant piriformis muscle bundle, as a seldom-diagnosed cause of sciatica and pelvic pain, for both neurosurgeons and neuropelveologists. The authors present the laparoscopic decompression technique for the pudendal and sciatic nerves by giving our technical "tips and tricks" enriched by a surgical video.

Transvaginal natural orifice endoscopic surgery for extremely obese patients with early-stage endometrial cancer.

AIM: The purpose of this study was to assess the feasibility and efficacy of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) staging surgery for extreme obese patients with early-stage type-1 endometrial cancer. METHODS: Study included cases of extreme obese patients with early-stage endometrial cancer who underwent v-NOTES between January 2019 and June 2019 at a tertiary referral medical center. The following parameters were noted: patient age, body mass index (BMI), operating time, conversion to conventional laparoscopy or laparotomy, any intraoperative or postoperative complications, estimated blood loss, pre- and postoperative hemoglobin levels, postoperative pain scores of the patients using visual analogue scale (VAS) at 6th, 12th and 24th h, length of hospital stay and final pathology report. RESULTS: Six cases of extreme obese patients with early-stage endometrial cancer underwent hysterectomy and bilateral salpingo-oophorectomy via the transvaginal NOTES. These six patients had a mean body mass index of 51.4 kg/m2 (SD = 6,13). No conversion to conventional laparoscopy or even laparotomy was needed in any of these patients. No adjuvant therapy was needed since all of the patients had early-stage endometrial carcinoma. CONCLUSION: Given the increased risk of surgical morbidity and mortality associated with increasing BMI, it is paramount importance to establish safe surgical approaches to gynecological pathologies. We think that v-NOTES offers greater benefit to obese patients when performed by an experienced surgeon and v-NOTES is a safe, effective and feasible minimally invasive surgery in extreme obese patients with early endometrial cancer.

Alternative method for the diagnosis of acid cases of unknown cause: Transvaginal natural orifice transluminal endoscopic surgery.

AIM: To evaluate the efficacy and reliability of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) technique in making the diagnosis of ascites with unknown cause. METHODS: Seven patients with ascites with unknown cause and diagnosed with vNOTES between November 2018 and May 2019 were analyzed retrospectively. The following data were collected retrospectively: body mass index, age, parity, previous abdominal or pelvic surgery, total operating time, perioperative complications and visual analog scale scores for evaluation of postoperative pain. After general anesthesia and disinfection, a 2-3 cm incision was made in the posterior fornix of the vagina. In all of the vNOTES procedures, a handmade glove port system comprised of a glove-wound retractor NOTES port was used. RESULTS: Transvaginal natural orifice transluminal endoscopic surgery for diagnostic peritoneoscopy was successfully performed in seven patients. Following postoperative pathological examination; three patients were established to have peritoneal carcinomatosis, one patient abdominal tuberculous, one patient ovarian fibroma, one patient ovarian mature cystic teratoma and one patient stomach cancer. In 1-year follow-up period after vNOTES procedure, no adverse events occurred in patients. CONCLUSION: In making histological diagnosis of ascites with unknown cause, vNOTES is a feasible, safe and efficient technique. Due to its high performance in diagnosis, this technique helps to initiate treatment early in some diseases in addition to preventing unnecessary treatment and examination in benign diseases. Besides, via obtaining a detailed and enlarged image of abdominal cavity, this procedure also guides the clinician in the evaluation of the suitability of patient for operation.

Impact of bupivacaine injection to trocar sites on postoperative pain following laparoscopic hysterectomy: Results from a prospective, multicentre, double-blind randomized controlled trial.

OBJECTIVES: Laparoscopic surgery has numerous advantages over open surgery in view of postoperative pain. In this context, to elevate its benefits and patient satisfaction, different pain management interventions have been used so far. This study aimed to evaluate the effect of bupivacaine injection to trocar sites following laparoscopic hysterectomy for the management of postoperative pain. STUDY DESIGN: In this study, patients were randomized into two groups (56 cases; 52 controls). A single injection of bupivacaine (0.5 %, 5 mg/mL) was introduced to trocar sites under subcutaneous tissue at a dose of 4 ml for the umbilicus and 2 ml for each 5-mm ancillary trocar site in the study group. No bupivacaine was administered to the control group. The primary aim was to measure differences in 2 -h postoperative numerical rating scale (NRS) pain scores between the two groups. The secondary aims were to evaluate differences between 1-, 4-, 6-, 24- and 48 -h postoperative NRS pain scores, surgical complications, estimated blood loss, duration of operation and analgesic consumption. RESULTS: The number of postoperative rescue doses of analgesics was found to be lower in the study group compared to the control group (median of 2 vs. 4; p < 0.01). The 1-, 4-, 6-, 24- and 48-hour postoperative NRS pain scores were also found to be lower in the study group compared to the control group (p < 0.01 at each follow-up). The mean duration of surgery and uterus removal, as well as the estimated blood loss, were not significantly different between the two groups. CONCLUSIONS: The present study suggests that bupivacaine injection to trocar sites is an effective and safe method for reducing pain following laparoscopic hysterectomy.

Superior Hypogastric Plexus Blocks for Postoperative Pain Management in Abdominal Hysterectomies.

OBJECTIVE: To evaluate the efficacy of intraoperative superior hypogastric plexus (SHP) blocks on postoperative pain management in abdominal hysterectomies. MATERIALS AND METHODS: A total of 78 female American Society of Anesthesiologists grade I or II patients who underwent elective total abdominal hysterectomy for benign reasons were assessed for eligibility. After exclusion of patients who did not fulfill the inclusion criteria, 60 patients were evaluated in 2 groups: patients who had intraoperative SHP block (SHP; n=30), and patients who did not have intraoperative SHP block (No-SHP; n=30). RESULTS: There was no statistically significant difference between the 2 groups in demographic attributes, surgical duration, and length of hospital stay. Opioid requirements in both the postanesthesia care unit and gynecology ward, and nonsteroidal anti-inflammatory drug requirements in the ward were statistically significantly higher in the No-SHP group (P<0.05). Rescue analgesic times were found to be significantly longer in the SHP group (627±352.9 min; P<0.05). All visual analogue scale score assessments were found to be statistically significantly lower in the SHP group (P<0.05). No complications related to the SHP blocks were observed. CONCLUSIONS: Intraoperative SHP blocks in abdominal hysterectomies appear to be promising methods for acute postoperative pain management as part of a multimodal analgesia regimen. Although single SHP blocks provide adequate pain relief and reduce analgesic consumption, these blocks might have better results when used together with somatic nerve blocks, including abdominal wall blocks or wound site infiltrations.