Search

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) combines the advantages of vaginal surgery with those of laparoscopic surgery. Feasibility of vNOTES for other indications such as hysterectomy, ovarian cystectomy and myomectomy has been established. In this article, we describe a standardised step by step process to perform adnexal surgery by vNOTES. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to evaluate the efficacy, safety, anatomical and functional outcomes of patients undergoing laparoscopic sacrocolpopexy (LSC) using light-weight Y mesh for post hysterectomy vaginal prolapse.Study Design: A retrospective observational study of women who underwent LSC for post hysterectomy vaginal vault prolapse between January 2010 and January 2019. Y shaped mesh was used for the LSC after dissection of the rectum and the bladder. Pre-operative evaluation included symptoms' assessment using the Prolpase Quality of Life Questionnaire (P-QOL) and objective assessment using the POP-Q scores. Post operatively, patient symptoms, anatomical outcomes, mesh complications and patient global impression of improvement scores were evaluated. Patients were followed up at 12 months and yearly thereafter.Results: 247 consecutive patients were included in this study. Patients' age ranged from 35 to 86 years old with an average BMI of 28.8. The most common presenting symptoms were vaginal bulge (95%), vaginal heaviness (73%) and urinary urgency (46%). The time interval between hysterectomy and LSC was 10.5 years (5 months - 42 years). Complications reported were bladder injury (1.6%), small bowel injury (0.8%), major haemorrhage (0.4%), vaginal mesh extrusion (1.2 %). 85.8% of women reported cure of prolapse symptoms. 14.2% of patients developed further/unresolved prolapse symptoms and 6.5% went on to have further surgery for prolapse. 10% of women developed new onset dyspareunia. Anatomically, postoperative point C (apex) was at -7.6 cm (range -9 - +3 cm) CONCLUSION: LSC using Y mesh for post hysterectomy vaginal prolapse is safe. LSC is effective in 85% of women who develop vaginal prolapse post hysterectomy. Further surgery for bothersome prolapse symptoms were needed in 6.5% with a 1.2% mesh extrusion rate and 10% new onset dyspareunia. This will help in counselling women undergoing this surgery. [ABSTRACT FROM AUTHOR]

Background: Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data.Methods: We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis.Results: Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD =  - 0.159 days, 95% CI [-0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD =  - 0.339, 95% CI [-0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD =  - 1.191 h, 95% CI [-1.836, -0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]).Conclusion: We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses. [ABSTRACT FROM AUTHOR]

Objective: Uterine fibroids are the most common benign tumours in women of the reproductive age. Symptoms of heavy menstrual bleeding, abdominal discomfort and infertility may seriously affect a woman's quality of life. Uterine artery embolization is a safe and effective alternative treatment to hysterectomy or myomectomy for symptomatic uterine fibroids. Which treatment provides the highest quality of life, least complications, symptom reduction and least chance intervention, has not been established and might depend on strict patient selection. This study aims to identify which specific subgroups benefit most of each treatment by analyzing individual participant data derived from randomized controlled trials of women undergoing embolization or surgical treatment. This study will primarily assess the effectiveness of both treatment groups by evaluating the effect on quality of life of embolization in comparison to surgery on specific patient and fibroid characteristics and the possible need for re-intervention for fibroid-related symptoms.Data Sources: PubMed/MEDLINE, Embase and The Cochrane Library were searched up to August 2020.Study Eligibility Criteria: We will collect individual participant data from randomized controlled trials that studied clinical and procedural outcomes of premenopausal women with symptomatic uterine fibroids, who were randomized between uterine artery embolization and surgery.Study Appraisal and Synthesis Methods: Individual participant data from all eligible trials will be sought and analysed according to intention-to-treat principle. Risk of Bias will be done by using version 2 of the Cochrane tool for Risk of Bias in randomized trials. Subgroup analyses to explore the effect of e.g. age, fibroid characteristics and fibroid complaints will be performed, if data is available. This individual patient data meta-analysis will be analysed according to a one-stage model. [ABSTRACT FROM AUTHOR]

Objectives: Fibroids are the most common benign tumours found in the uterus and can cause various symptoms. In 20-50 % of the women, an intervention is required. When conservative options fail, invasive options such as hysterectomy, uterine artery embolization or myomectomy are eligible options. Ulipristal acetate (UPA) was launched as the sole available long term pharmaceutical treatment, with the potential to avoid surgery. It is suggested that UPA improves quality of life, reduces symptoms and fibroid volumes. However, UPA is an expensive medicine, is possibly associated with liver injury and has never been directly compared to surgical treatment. The aim of this trial is to compare UPA to surgical treatment on both effectiveness and cost-effectiveness. Primary outcome is the reduction in symptom severity scores (part of the Uterine Fibroid Symptom and Quality of Life questionnaire) at 24 months of follow-up compared to baseline. Secondary outcomes include quality of life, societal costs, societal participation, liver function variation, patient satisfaction and preference. Outcomes will be analysed according to intention-to-treat principle.Study Design: The MYOMEX-2 trial is an open-label, multicentre, non-inferiority randomized controlled trial. Patients are pre-menopausal women with symptomatic fibroids eligible for surgical treatment (hysterectomy, myomectomy or UAE). Fibroid symptoms may comprise (but are not limited to) heavy menstrual bleeding, bulk symptoms or pain. Patients are randomised 2:1 in a parallel group design between two treatment arms: 119 patients in the UPA group and 60 patients in the surgery group. Follow up comprises of online questionnaires, outpatient visits and phone appointments on several follow up moments, up to 24 months after surgery or start UPA.Registration Details: MYOMEX-2 trial; protocol version 4, date 22-02-2019; NTR6860; NL62638.029.18. All items from the World Health Organization Trial Registration Data Set are provided in the online supplementary file (Appendix-B). [ABSTRACT FROM AUTHOR]

Objective: To determine the trends of hospitalization (inpatients and outpatients) for uterine leiomyomas in Portugal, over a period of fifteen years.Study Design: We perform a population- and register-based retrospective study of women who were hospitalized with a primary diagnosis of uterine fibroid in public hospitals in continental Portugal, in the period between January 1, 2000 and December 31, 2015. Patient data regarding hospital codes, admission and discharge dates, patient age, diagnosis, procedures and complications were extracted from the national database of Administração Central do Sistema de Saúde (ACSS). All calculations were performed with the STATA software, version 13.1. Categorical data were analysed by the χ2 test and the means of continuous variables were analysed with Student's t-test. Statistical significance was set at p < 0.05.Results: Between 2000 and 2015, 102 476 patients were admitted to public hospitals in Portugal due to uterine leiomyomas. The majority were admitted to hospital for surgery: 73.6 % for hysterectomy and 13.0 % for myomectomy. During this period, the definitive treatment (hysterectomy) decreased from 83.2% to 63.0% (p < 0.001), with a change towards more conservative treatments such as myomectomies (6.4% to 22.6%, p < 0.001). Additionally, in women submitted to hysterectomy, laparoscopic and vaginal routes increased (1.1%-11.5%, p < 0.001 and 2.1%-4.0%, p < 0.001; respectively). Globally, there was a 14.3 % reduction in hospitalizations due to uterine fibroids and an increase in the outpatient rate (from 3.1% to 22.1%). The mean number of hospitalization days for inpatients also decreased (from 6.3 ± 4.1-4.0 ± 3.0, p < 0.001). Regarding urgently hospitalized women, 11.8 % required a blood transfusion. In women submitted to surgical procedures, 0.5 % had an intraoperative complication and 2.3 % a post-operative complication, directly related to the surgical procedure.Conclusion: There was a reduction in hospitalizations due to uterine fibroids and a change towards more conservative treatments. [ABSTRACT FROM AUTHOR]

Objective: Advanced vaginal vault prolapse (VVP) can occur rarely after any type of hysterectomy. Several types of procedures have been applied to correct this defect, but optimal management is still pending. The aim of this study was to describe the surgical technique and results of four-arm transvaginal mesh (FATVM) application for advanced VVP.Study Design: We followed up for 24 months, 160 patients with VVP > II vc (according to the Pelvic Organ Prolapse Quantification Scale (POPQ)), who underwent FAMTVM from 2014 to2017. FAMTVM was inserted with the anterior arms through the obturator foramens and the posterior arms through the ischiorectal fossas and sacrospinal ligaments. Clinical data were prospectively collected in a customized database and retrospectively analyzed. To assess QoL SF 36, KHQ and FSFI questionnaires were used. POPQ was employed to measure degree of VVP. Non-parametric tests (The Wilcoxon signed-rank test) were applied to verify statistical hypotheses.Results: According to SF 36, significant improvement was evident in almost all aspects of general QoL (PCS p = 0.002, MCS p = 0.01). KHQ showed statistically significant improvement in all domains. FSFI scores after surgery indicated significantly improvement in all domains of the questionnaire, apart from lubrication (p = 0.02). Intraoperative bladder injury occurred in 3.75 % (n = 6) of all cases. Five patients (3.1 %) complained of de novo stress urinary incontinence. VVP reoccurred in nine cases (5.6 %). Only two patients (1.25 %) saw mesh exposure after 6 months postoperative recovery.Conclusion: We consider FAMTVM for VVP to be safe and effective. Hence, it applied as an optional treatment, especially in patients with contraindications to laparotomy and laparoscopy. [ABSTRACT FROM AUTHOR]

Objective: To interpret the long-term outcomes of transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy in patients with stage 3-4 uterovaginal prolapse.Study Design: This retrospective case-control study from 2007 to 2016 analysed patients' medical records and evaluated gynaecological examinations over 11 years of follow-up. One hundred and forty-three patients who underwent transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy were evaluated. The prespecified primary outcome evaluated at 11-year follow-up was apical prolapse of stage 2 or higher evaluated by the Pelvic Organ Prolapse Quantification System (POP-Q), in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. The secondary outcome was overall anatomical failure (recurrent prolapse of stage 2 or higher in apical, anterior or posterior compartment). The rate of recurrence of apical prolapse was compared between groups using the McNemar test.Results: The mean (± standard deviation) follow-up period was 88.15 ± 2.519 months (95 % confidence interval 83.17-93.13). The pre-operative diagnoses were stage 3 uterovaginal prolapse in 23 (16.08 %) patients, stage 4 uterovaginal prolapse in 120 (83.91 %) patients, rectocele in 119 (83.21 %) patients, cystocele in 138 (96.50 %) patients and stress urinary incontinence in 53 (37.06 %) patients. Ten (8.33 %) patients with stage 4 uterovaginal prolapse developed postoperative apical prolapse, whereas none of the patients with stage 3 uterovaginal prolapse developed postoperative apical prolapse. Postoperatively, the POP-Q stages of apical prolapse were significantly lower compared with pre-operatively (p < 0.001). Postoperatively, the apical prolapse rate was 7.0 %, the recurrent cystocele rate was 2.07 %, the recurrent rectocele rate was 5.5 %, and the recurrent stress urinary incontinence rate was 18.87 %. Overall, postoperative anatomical failure occurred in 21 of 143 (14.68 %) women. One (0.69 %) patient developed perioperative bladder perforation, two (1.39 %) patients experienced voiding difficulty, and eight (5.59 %) patients experienced vaginal spotting.Conclusion: Transvaginal round-infundibulopelvic ligament colposuspension during vaginal hysterectomy is an effective and useful method that reduces the rate of postoperative apical prolapse in patients with high-grade uterovaginal prolapse. [ABSTRACT FROM AUTHOR]

Objective: Evaluation of five years follow up of the clinical recurrence after hysteroscopic myomectomies with MyoSure® morcellator in our district.Study Design: Premenopausal patients from April 2013 to October 2018, with symptoms of abnormal uterine bleeding, and/or infertility, and sonographic suspicion of submucosal myoma, confirmed by diagnostic hysteroscopy prior to myomectomy were included in the prospective, not randomized cohort study (N = 320). All patients had a follow up visit between three to six months post procedure. Further follow up was established by chart review. The information was extracted from the medical records. Patient characteristics were expressed as mean ± SD or median (interquartile range) for continuous data (assumption of normality assessed using the Kolmogorov-Smirnov test). Dependence relationship between presence of corporal myomas and the performance of a major long-term surgery, and between the amount of submucosal myomas and clinical recurrence throughout the 5 years of follow-up were studied were studied by χ2.Results: After one year follow up, no recurrence or symptoms were noted. 53 (16.6%) re-morcellations were performed due to incomplete resection. At the second year, three women who were discharged previously were classified as recurrence (0.9%). There were 99 women remaining to be evaluated (30.90%) in the second year. A percentage estimation of 5-6 recurrences with the 100% of women evaluated. In the third year, only one woman was classified as recurrence (0.3%), with 176 (55%) women not evaluated. At the fourth and fifth year of follow-up, 75% are still awaiting complete of the study five years. No relationship was observed in the presence of corporal myomas and recurrence throughout the 5 years of follow-up (χ2 = 0.000, p = 0.994). Dependence relationship was observed between the presence of corporal myomas and the performance of a major long-term surgery (χ2 = 11.757, p = .001, OR = 3.528).Conclusion: In office hysteroscopic mechanical myomectomy with MyoSure® morcellator of submucosal fibromas was a highly effective therapy for women, at three years of follow-up. It appears to give satisfactory long-term results with a low recurrence rate and without significant complications. [ABSTRACT FROM AUTHOR]

Objectives: The aims of the study were to develop and gather validity evidence for a feasible rating scale for formative and summative assessment of total laparoscopic hysterectomy in the operating theatre.Study Design: The study was a prospective observer-blinded cohort study. The rating scale was developed according to the generic format of Objective Structured Assessment of Technical Skills. We applied the contemporary framework of validity to examine validity evidence of the content, response process, internal structure, relationship to other variables, and consequences. Two experienced gynecologists constructed a preliminary version of the rating scale, which was reviewed by a multicentre team of experienced gynecologists in a modified Delphi process. The surgeons (beginners and experienced surgeons) were video recorded during live performance of total laparoscopic hysterectomies. Two blinded raters evaluated the performances independently using the rating scale. Internal consistency reliability and interrater reliability were calculated as measures of internal structure. The performances of the two groups were compared and a pass/fail score was set to show the consequences of the rating scale.Results: The content of the rating scale was defined during three Delphi rounds and upon agreement comprised of 12 items. Sixteen participants including 8 beginners and 8 experienced surgeons performed total laparoscopic hysterectomies. The internal consistency reliability of the items was 0.95 (Cronbach's alpha), and the interrater reliabilities (Intraclass Correlation Coefficient, absolute agreement) were 0.996 for one rater and 0.998 for two raters (P <  0.001 for all correlations). The beginners' mean performance score was 19.2 (SD 7.1) and the experienced surgeons' score was 36.4 (SD 3.9); the groups performed statistically significantly different (P <  0.001). The pass/fail score was 29.3 with no false positives and no false negatives.Conclusion: With this study, a feasible rating scale for the objective assessment of total laparoscopic hysterectomy was developed with sound validity evidence. The rating scale is suitable for both formative and summative feedback in the commencement of surgical training in gynecology. [ABSTRACT FROM AUTHOR]

Objectives: Our objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas.Study Design: We retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016.Results: Twenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51-60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1-25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1-3 months. Seventeen patients had no relapse and were alive for 6-41 (mean 24) months.Conclusions: Our study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation. [ABSTRACT FROM AUTHOR]

Objectives: The present study aimed to analyze the clinicopathologic features and treatment of uSTUMP in a single institution. In addition, we described the obstetric outcomes after uterine-preserving surgery for uSTUMP.Methods and Materials: A retrospective chart review was performed of patients diagnosed with uSTUMP between January 2000 and February 2018 at the Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center. We obtained data on the patients' demographics, treatment, therapeutic results, time to recurrence, disease-free and overall survival, and subsequent obstetric outcomes. The central pathology reviews were carried out by two pathologists specializing in gynecologic oncology.Result: A total of 19 patients diagnosed with uSTUMP were identified and included in the study. The mean age at diagnosis was 41 years (range 28-49 years). Frozen sections were performed in 11 patients including five patients during surgery. Nine of the 19 patients (47.4%) were treated by hysterectomy and 10 patients were initially treated by myomectomy. The mean follow-up period was 47 months (range 6-209 months). Two patients (10.5%; 2/19) experienced recurrence. Although not defined as recurrence in the present study criteria, one patient had a secondary diagnosis of atypical leiomyoma one year after the initial diagnosis of uSTUMP. Seven patients requested uterine-preserving treatment, five of whom wanted to become pregnant. Three of them (3/5; 60%) successfully delivered live birth to full term by Cesarean section without complications such as abortion, preterm delivery or uterine rupture, and tumor recurrence.Conclusions: The present study describes the clinicopathologic data of uSTUMP patients. Our results suggest a uSTUMP recurrence of 10.5%, comparable to previous reports. Although there is a possibility of malignant recurrence, fertility-preserving management is worth attempting because of relatively low affected age with careful close follow-up. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to investigate the incidence of unexpected uterine malignancy (UUM) diagnosed after hysteroscopic surgery for presumed submucosal leiomyomas or endometrial polyps.Study Design: From the Korean national health insurance database between January 1, 2009 and December 31, 2015, we analyzed inpatient sample data that were extracted by a stratified random sampling (gender and age) method. We extracted women with or without UUM that was diagnosed after hysteroscopic surgery using diagnosis codes and procedure codes.Results: A total of 11,866 women who underwent hysteroscopic surgery were extracted from 4,476,495 women. The mean age of the patients who underwent hysteroscopic surgery was 37.8 ± 0.1 years. A hysteroscopic myomectomy or polypectomy was performed in 3498 and 8368 women, respectively. The incidence of UUM diagnosed after hysteroscopic myomectomy or polypectomy was 0.86% and 1.11%, respectively. The logistic regression analysis showed that the risk of UUM increased with age (Odds Ratio (OR), 1.61; 95% Confidence Interval (CI), 1.47-1.77; P < 0.001) and did not indicate hysteroscopic myomectomy or polypectomy (OR, 1.21; 95% CI, 0.93-1.55; P = 0.151).Conclusions: The incidence of UUM diagnosed after hysteroscopic myomectomy (0.86%) or polypectomy (1.11%) was higher than that of UUM diagnosed after hysterectomy (0.19%) or myomectomy (0.12%) for presumed benign leiomyoma. The incidence of UUM increased over the age of 50. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to evaluate the pharmacoeconomic profile in Italy of preoperative treatment with ulipristal acetate at the dose of 5 mg/day for 13 weeks in comparison with placebo prior to surgical management of symptomatic uterine fibroids.Study Design: The pharmacoeconomic analysis was based on the calculation of incremental cost-effectiveness ratio (ICER). Effectiveness data were derived from the randomized-controlled trial PEARL-1, whilst costs data were retrieved from the published literature. A Markov model was employed to simulate the pattern of costs and two univariate sensitivity analyses tested the robustness of the results.Results: In comparison with placebo, ulipristal acetate 5 mg for presurgical therapy was estimated to be associated with an incremental cost of €351 per patient. Costs per patient were €3836 for ulipristal acetate vs €3485 for placebo. The incremental effectiveness was 0.01931 QALYs per patient (around 7 quality-adjusted days per patient). Hence, the cost effectiveness ratio was calculated to be €18,177 per QALY gained.Conclusions: Preoperative use of ulipristal acetate 5 mg in patients with uterine fibroids has a favourable pharmacoeconomic profile. [ABSTRACT FROM AUTHOR]

Objective: This project of the International Society for Gynecologic Endoscopy (ISGE) had the objective to review the literature and provide recommendations on the occult sarcoma risk assessment in patients who are candidates for minimally invasive gynecological surgery involving intra-abdominal electromechanical tissue morcellation.Study Design: The ISGE Task Force for Estimation of the Risk in Endoscopic Morcellation initially defined key topics and clinical questions which may guide a comprehensive preoperative patient assessment. A literature search within the Medline/PubMed and Cochrane Database was carried out using keywords "morcellation", "uterine fibroids", "uterine sarcoma", "myomectomy" and "hysterectomy". Relevant publications (original studies, meta-analyses and previous reviews), written in English and published until May 30th, 2017, were selected and analyzed. Previously emitted statements of 12 recognized professional societies or government institutions and their supporting literature were also studied. For each topic/clinical question, the available information was graded by the level of evidence. The ISGE recommendations were established in accordance with the evidence quality.Results: In the light of available information, 9 recommendations on preoperative clinical, laboratorial and imaging evaluation of the candidates for intracorporeal uterus/leiomyoma morcellation were formulated, mainly based on consensus and expert opinions. There is a lack of high-quality evidence, which does not allow the establishment of strong recommendations.Conclusion: Electromechanical tissue morcellation may be used in gynecological patients who are considered "low risk" upon appropriate preoperative evaluation; however, further studies and prospective data collection are greatly needed to improve sarcoma risk assessment in women with presumed uterine leiomyomas. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of undiagnosed uterine leiomyosarcoma (LMS) in women undergoing hysterectomy or myomectomy for suspected benign leiomyomas.Study Design: Retrospective, single-centre, cohort study. Information for all gynaecological procedures for suspected benign leiomyomas between 1993 and 2016 was extracted from the hospital database. The prevalence of LMS was calculated by surgery type and age group.Results: The prevalence of LMS was 1.7/1000 [one in 603 women; 95% confidence interval (CI) 0.8-3.4] for all procedures combined. The prevalence of LMS was 1.1/1000 (one in 875 women; 95% CI 0.4-2.9) for all hysterectomies combined and 4.2/1000 (one in 240 women; 95% CI 1.4-12.2) for all myomectomies combined. For women aged <50years, the prevalence of LMS was 5.4/1000 (one in 187 women; 95% CI 1.8-15.6) for abdominal hysterectomies, 1.0/1000 (one in 1040 women; 95% CI 0.2-5.4) for laparoscopic hysterectomies, 5.2/1000 (one in 191 women; 95% CI 0.9-29.1) for abdominal myomectomies, 3.0/1000 (one in 332 women; 95% CI 0.5-16.9) for laparoscopic myomectomies and 8.6/1000 (one in 116 women; 95% CI 1.5-47.2) for hysteroscopic myomectomies.Conclusions: Occult LMS is a rare malignant disease. This study found that the prevalence of LMS was higher in women undergoing myomectomy compared with women undergoing hysterectomy. The highest prevalence of LMS was found in women undergoing hysteroscopic myomectomy. [ABSTRACT FROM AUTHOR]

Objectives: To establish the trends in pelvic floor surgery in Finnish female population and to evaluate the age-specific incidence as well as the lifetime risk for pelvic organ prolapse surgery.Study Design: We conducted a population-based register study, which includes all Finnish women (n=77 906), who underwent surgery for pelvic organ prolapse in Finland 1987-2009. The women were identified in the Care Register for Health Care based on the procedure codes. Number of procedures, age-adjusted incidence, age-specific incidence, cumulative incidence, lifetime risk were calculated.Results: A total of 93 226 surgical procedures for POP were performed. The age-adjusted incidence of prolapse surgery was 1.3/1000 women in 1987. After that there was an increase which peaked in 1996 with 1.9/1000, and a decline thereafter back to 1.3/1000 in 2009. The lifetime risk for a woman to have undergone at least one surgical procedure for prolapse was 12.8%. Surgery was most common within women aged 70 to 79 years, followed by women aged 60 to 69 years. The most popular procedure until 1991 was cervix amputation with colporraphies, surpassed thereafter by colporraphies only or with combined vaginal hysterectomy.Conclusion: Surgery for pelvic organ prolapse is common and more than every tenth woman underwent such surgery during lifetime. [ABSTRACT FROM AUTHOR]

Objective: We primarily aimed to evaluate the effectiveness of the novel technique: bilateral sacrospinous fixation by monofilament polypropylene apical sling combined with "neocervix" formation in surgical treatment of post - hysterectomy vaginal vault prolapse. The secondary objective was to estimate the impact of the surgery on voiding function and quality of life.Study Design: This prospective study involved 61 women suffering from post-hysterectomy prolapse. We used the following criteria to evaluate the results of surgical treatment: results of vaginal examination (POP-Q system), uroflowmetry, bladder ultrasound, validated questionnaires were used. All listed parameters were determined before the surgery and at control examinations in 1, 6, 12 months after the treatment.Results: Mean operation time was 35min. No cases of intraoperative damage to the bladder/rectum, as well as clinically significant bleeding were noted.At 12-month follow-up anatomical cure rate (≤stage I, POP-Q) was 100%, 94,4% and 100% for vaginal apex, anterior and posterior vaginal walls, respectively. The following long-term complications were noted stress urinary incontinence de novo and urgency de novo were noted in 6.5% and 4,9%, respectively. Statistically significant (P<0.05) improvement in peak flow rate was observed according to uroflowmetry. Comparison of the scores by the questionnaires revealed a significant improvement in the quality of life in the postoperative period.Conclusion: The novel technique: combination of the apical sling and purse-string "neocervix" formation appears to be effective and safe method for treatment patients with vaginal vault prolapse. The technique improves voiding function and quality of life. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to compare surgical outcomes following conventional laparoscopic hysterectomy (LH) (C-LH) versus the combination method of LH plus laparoscopic myomectomy (LM) (LH+LM) for the treatment of large uterine fibroids.Study Design: This study was performed in 56 patients (uterine weights ≥500g) who underwent either C-LH or LH+LM performed by the same surgeon between May 2010 and May 2016. LH+LM was performed when C-LH was problematic because of poor visibility and/or mobility due to uterine fibroids.Results: The C-LH and LH+LM groups consisted of 27 (48%) and 29 (52%) patients, respectively. The clinical characteristics of patients differed significantly only in the median sizes of the dominant fibroid. The sizes of the dominant fibroid in the C-LH and LH+LM groups were 9.5cm and 10.7cm (P=0.04), respectively. Regarding the surgical outcomes for the C-LH and LH+LM groups, the median uterine weights were 558g and 737g (P=0.03), respectively, the median operating times were 156min and 173min (P=0.23), respectively, and the median intraoperative blood losses were 150g and 300g (P=0.0004), respectively. In all patients, LH was performed without conversion to laparotomy and there were no cases of bladder, ureteral, or gastrointestinal tract injury. There were no postoperative complications of Clavien-Dindo scale≥III in either group.Conclusions: When C-LH cannot be performed because of large uterine fibroids that cause poor visibility and/or mobility, LH+LM may allow the procedure to be successfully completed without conversion to laparotomy. However, the latter approach increases the risk for intraoperative blood loss. [ABSTRACT FROM AUTHOR]

Objectives: To characterize and describe treatment with Ulipristal acetate (UPA) in a pre-operative setting and to evaluate the safety, effectiveness, and Health Related Quality of Life (HRQoL) outcomes in a population treated according to standard clinical practice in the EU.Study Design: Multi-centre, prospective, non-interventional study (PREMYA) of patients diagnosed with moderate to severe symptoms of uterine fibroids and undergoing a pre-operative treatment with UPA (Esmya®) at 73 clinical practice sites within the EU. Patients were followed during UPA treatment and for 12 months after treatment discontinuation for a total of 15 months follow-up. Data was collected every 3 months in accordance with standard care visits.Results: A total of 1568 women were enrolled, of whom 1473 were found to be eligible for data analysis. Only 38.8% of patients underwent surgery, of which the majority were of a conservative/minimally invasive nature. Physicians' assessments of patients' overall symptomatic change, as measured on the Clinical Global Impression-Improvement (CGI-I) scale, indicated that 60% of patients were much improved or very much improved at 3 months. Pain and quality of life after treatment cessation remain lower than baseline during the entire period of follow-up CONCLUSIONS: The majority of patients do not undergo surgery immediately after treatment cessation. Quality of life and pain are highly improved by Esmya® treatment. [ABSTRACT FROM AUTHOR]

Objective: To critically appraise studies comparing benefits and harms in women with benign disease without prolapse undergoing hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) versus laparoscopy.Study Design: We followed the PRISMA guidelines. We searched MEDLINE, EMBASE and CENTRAL for randomised controlled trials (RCTs), controlled clinical trials (CCTs) and cohort studies comparing NOTES with laparoscopy assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH) in women bound to undergo removal of a non-prolapsed uterus for benign disease. Two authors searched and selected studies, extracted data and assessed the risk of bias independently. Any disagreement was resolved by discussion or arbitration.Results: We did not find RCTs but retrieved two retrospective cohort studies comparing NOTES with LAVH. The study quality as assessed by the Newcastle-Ottawa scale was acceptable. Both studies reported no conversions. The operative time in women treated by NOTES was shorter compared to LAVH: the mean difference (MD) was -22.04min (95% CI -28.00min to -16.08min; 342 women; 2 studies). There were no differences for complications in women treated by NOTES compared to LAVH: the risk ratio (RR) was 0.57 (95% CI 0.17-1.91; 342 women; 2 studies). The length of stay was shorter in women treated by NOTES versus LAVH: the MD was -0.42days (95% CI -0.59days to -0.25days; 342 women; 2 studies). There were no differences for the median VAS scores at 12h between women treated by NOTES (median 2, range 0-6) or by LAVH (median 2, range 0-6) (48 women, 1 study). There were no differences in the median additional analgesic dose request in women treated by NOTES (median 0, range 0-6) or by LAVH (median 1, range 0-5) (48 women, 1 study). The hospital charges for treatment by NOTES were higher compared to LAVH: the mean difference was 137.00 € (95% CI 88.95-185.05 €; 294 women; 1 study).Conclusions: At the present NOTES should be considered as a technique under evaluation for use in gynaecological surgery. RCTs are needed to demonstrate its effectiveness. [ABSTRACT FROM AUTHOR]

Background: Parasitic leiomyomas were first described as early as 1909 but are a rare condition. In recent years, due to the rise of laparoscopic surgery and power morcellation, several cases of parasitic leiomyomas associated with this surgical procedure have been reported.Methods: A literature search was performed using PubMed, Embase and Google Scholar with the following combination of keywords: leiomyoma OR uterine neoplasms OR uterine myomectomy OR laparoscopy OR hysterectomy OR peritoneal neoplasms AND parasitic. Papers describing parasitic leiomyomas were included. The results of these studies are summarized herein.Results: We retrieved abstracts of 756 papers. Of these, 591 were excluded for not fulfilling the inclusion criteria and 54 were removed as duplicates; after full-text assessment, 8 were rejected for presenting cases of malignancy and finally 103 were included in our systematic review. From these, we present information about 274 patients with parasitic leiomyomas. The mean age of women was 40 years (range 18-79 years); and 154 (56%) had no history of uterine surgery, the others (120, 44%) having had a previous myomectomy or hysterectomy. Of the total, 106 (39%) women had a history of power morcellation. The most frequent clinical symptom was abdominal pain (49%) and the most frequent presentation was disseminated peritoneal leiomyomatosis.Conclusions: While parasitic leiomyoma was first described a century ago, the recent introduction of laparoscopic power morcellation has increased the number of reported cases. [ABSTRACT FROM AUTHOR]

Objective: To evaluate a modified single-access method of contained power morcellation performed with a single-access laparoscopic device and a new cordless electric morcellator. The study was a preliminary assessment of the feasibility and safety of the new technique.Study Design: A single university hospital observational study involving patients who underwent either laparoscopic myomectomy or laparoscopic hysterectomy. We evaluated the operative results, time required for the contained morcellation, any occurrence of bag leakage, and any complications.Results: The new contained power morcellation technique was applied in 12 patients (9 undergoing laparoscopic myomectomy and 3 undergoing laparoscopic hysterectomy). The mean bag introduction time was 21.8min (range, 14-37min); mean in-bag morcellation time was 11.5min (range, 1-26min); and mean total morcellation time was 36.8min (range, 19-66min). Visual inspection revealed no bag damage. There were no postoperative complications.Conclusion: Single-site in-bag morcellation performed with our new technique requires neither bag penetration nor piercing with a trocar and thus may prove beneficial for preventing spillage and dissemination of unwanted cells and tissue. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the etiologies of adnexal masses requiring reoperation in women with prior hysterectomy and to compare incidence and pathology of these masses based upon whether total, partial or no adnexectomy was performed at time of hysterectomy. In addition, the average time interval between hysterectomy and reoperation for a pelvic mass is ascertained.Study Design: A single-institution, retrospective review spanning 10 years. Using pertinent ICD-9 and CPT codes, women with a history of hysterectomy who underwent a subsequent surgery for an adnexal or pelvic mass were identified.Results: Over ten years, 250 women returned for gynecologic surgery due to a pelvic mass after prior hysterectomy. Most had undergone hysterectomy only (76%). 64.8% of these women had masses of ovarian origin, 12.4% were tubal in origin, 20% of masses involved both the ovary and tube and a small proportion arose from non-gynecologic processes. 18% of these women had a malignancy; 80% were ovarian and 6.7% originated from the fallopian tube. Patients having had a prior hysterectomy and bilateral salpingectomy returned soonest (p<0.0001) and patients with malignant masses returned after the longest time intervals (HR 0.41, p<0.0001).Conclusions: The majority of adnexal masses requiring reoperation after hysterectomy are gynecologic in origin, benign, and arise from the ovary. Women returning with malignant masses after hysterectomy present after longer time intervals. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to estimate the incidence of uterine leiomyosarcoma in patients with leiomyomas following laparoscopic supracervical hysterectomy and myomectomy procedures.Study Design: For this study, we analyzed records of 13,964 women aged 25-64 years who underwent laparoscopic supracervical hysterectomies or myomectomies for leiomyomas from 2002 to 2011 using Clinformatics DataMart. Patient records were divided into two groups: history of laparoscopic supracervical hysterectomy and history of myomectomy. Subjects were tracked to identify diagnosis of leiomyosarcoma within 1 year of the procedure. We analyzed data from the 25-39, 40-49, and 50-64 age brackets. Evidence was obtained from a cohort study from national private insurance claims in the US.Results: Our results showed the incidence of occult leiomyosarcoma developing within 1 year following supracervical hysterectomy using a laparoscopic-assisted approach are 9.8, 10.7, and 33.4 per 10,000 for the 25-39, 40-49, and 50-64 age brackets, respectively; the overall incidence rate is 13.1 per 10,000. The incidence rate of occult leiomyosarcoma developing within 1 year following myomectomy using a laparoscopic-assisted approach are 0.0, 33.8, and 90.1 per 10,000 for the 25-39, 40-49, and 50-64 age brackets, respectively; the overall incidence rate is 17.3 per 10,000.Conclusion: Our analysis shows the overall risk of being diagnosed with occult leiomyosarcoma is 12.9 per 10,000 in laparoscopic-assisted supracervical hysterectomy and myomectomy for patients younger than 49. There is no evidence of occult leiomyosarcoma 1 year after operation for patients younger than 40 who underwent laparoscopic myomectomy. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of hysterectomy and uterus-preserving procedures (UPPs) among women with uterine fibroids (UFs) and the incidence of further procedures after a UPP.Study Design: This was an observational study using a primary care database, The Health Improvement Network (THIN). Women in THIN with UFs aged 15-54 years between January 2000 and December 2009 were eligible for study. The UPPs examined were myomectomy, endometrial ablation (EA) and uterine artery embolization (UAE). Using Read codes, women were followed up until one of the following was met: there was a record of hysterectomy or UPPs, they died or the study ended (end of 2010).Results: The cumulative incidence of hysterectomy or UPPs was 23.6% at 1 year, and 40.9% after the follow-up period (median 3.6 years). At the end of the follow-up period, the cumulative incidences of hysterectomy, myomectomy, EA and UAE were 33.0%, 3.9%, 6.4% and 1.9%, respectively. For women initially treated with a UPP, the cumulative incidence of second procedures was 11.5% at 1 year. At the end of the follow-up period (median 2.7 years), the cumulative incidence of further procedures was 26.1%, and the cumulative incidences of women undergoing hysterectomy, myomectomy, EA and UAE were 19.0%, 4.3%, 3.4% and 1.4%, respectively.Conclusions: Women considering UPPs for the management of UFs should be made aware that the incidence of further treatments is high, with hysterectomy being the most frequent procedure undergone. [ABSTRACT FROM AUTHOR]

Abstract: To determine the effectiveness of transversus abdominis plane blocks in gynecological surgery by systematic review and meta-analysis. Embase, MEDLINE and the Cochrane Library (CENTRAL) bibliographic databases were searched using a Cochrane Library search strategy modified for gynecological surgery. We included randomized controlled trials comparing transversus abdominis plane block with no block or placebo block. We retrieved 681 citations from which we included five published studies (225 randomized participants) which fulfilled our inclusion criteria, and identified a further six ongoing studies. Quality was assessed across six risk of bias domains: randomization sequence generation, allocation concealment, blinding, missing outcome data, selective reporting and other biases. Data were meta-analyzed where possible and presented as mean differences with 95% confidence intervals. Study quality was moderate. Compared with no block or saline placebo, transversus abdominis plane block provided significantly less postoperative pain at rest on a 10cm visual analog scale at 2h (mean difference −2.14cm, 95% confidence interval (CI) –3.57 to −0.71) but not at 24h postoperatively (–0.52cm, 95% CI –1.49 to 0.45). Pain on movement showed similar results. Transversus abdominis plane block resulted in significantly less postoperative requirement for morphine use at 24h (−11.76mg, 95% CI −18.77 to −4.75) but not at 48h (−16.01mg, 95% CI −39.40 to 7.39). Evidence exists for the short-term efficacy (within 24h) of transversus abdominis plane blocks during hysterectomy in terms of reported pain and morphine consumption, which may not be sustained at 48h. Updates to this review should be undertaken periodically, and until further robust evidence is available, anesthetists should not rush to adopt this procedure into routine practice. [Copyright &y& Elsevier]

Abstract: Objective: To compare re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH). Study design: Retrospective analysis of 867 women who underwent laparoscopic hysterectomy between January 2002 and December 2009 for benign gynaecological diseases. Total laparoscopic hysterectomy was performed in 567 women (TLH group) and laparoscopy-assisted supracervical hysterectomy was performed in 300 women (LASH group). Results: The women in the LASH group were significantly younger (45.6years) than those in the TLH group (47.9years) and the uteri removed with LASH were significantly heavier (326.4g) than those removed with TLH (242.7g). The rate of salpingo-oophorectomy was significantly lower in the LASH group. The overall re-operation rates were equivalent in the two groups. Two method-specific reasons for re-operations were identified. A method-specific procedure after LASH was extirpation of the cervical stump, which was performed in 2.7% of the women. Vaginal cuff dehiscence was a method-specific problem leading to secondary operation after TLH and was observed in 0.7% of the patients. No differences between the intraoperative and postoperative complication rates were observed, although there was a trend toward lower complication rates after LASH. Conclusions: There seem to be equivalent overall re-operation rates and complication rates after both hysterectomy procedures, making the two laparoscopic approaches for hysterectomy equivalent. [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate image findings in the junctional zone (JZ) in patients with endometriosis and correlate with image findings of adenomyosis. To attempt a correlation of the degree of adenomyotic infiltration with the degree of infiltration and stage of endometriosis. Study design: Magnetic resonance imaging (MRI) of the uterus was performed in 153 women with suspected deeply infiltrating endometriosis and planned surgery, and in a reference group of 129 women without endometriosis, verified during hysterectomy. Changes in the JZ and endometriosis in the pelvis were described in detail. Diagnosis of adenomyosis at MRI was based on optimal criteria derived from the hysterectomy control group. The stage of endometriosis (AFS stage) was determined during surgery. Results: In the group of women with endometriosis 34.6% had adenomyosis compared with 19.4% in the reference group (p <0.05). More women with endometriosis (39.9%) had an irregular JZ compared to 22.5% in the reference group (p <0.01). Among women with severe endometriosis (AFS stage IV) 42.8% had adenomyosis compared to 29.4% in the women with other stages of endometriosis (AFS stages I+II+III) (p =0.10). More women with severe endometriosis (AFS stage IV) had deeper wall invasion of adenomyosis (p >0.05) but the presence of deep infiltrative rectovaginal endometriosis and the size of infiltration were not correlated to adenomyosis or depth of infiltration of adenomyosis. Conclusions: In a group of young women with severe symptomatic endometriosis and planned surgery a systematic evaluation of the JZ revealed that one third had uterine adenomyosis, but the invasive potential of endometrial cells in the uterus and in the peritoneum corresponded only to a limited degree. [Copyright &y& Elsevier]

Abstract: Hysterectomy is a very common gynaecological procedure. The vaginal route is considered preferable for hysterectomy, although the ideal route for women unsuitable for the vaginal approach remains unclear. We performed a meta-analysis of published randomised controlled trials to compare outcomes in total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) for benign disease. Pooled odds ratios (OR) were calculated for categorical variables using random effects models as per Der Simonian and Laird. Continuous variables were compared by means of weighted mean differences (WMD). TLH is associated with reduced overall peri-operative complications (pooled OR 0.19; 95% CI 0.07–0.50) and reduced estimated blood loss (WMD −183ml; 95% CI −346ml to −21ml; p =0.03). Additionally, there are trends towards shorter hospital stay (WMD −2.5 days; 95% CI −5.1 days to 0.01 days; p =0.05) and post-operative haematoma formation (pooled OR 0.17; 95% CI 0.03–1.01) compared to TAH. The only trade-off appears to be a longer operating time in the TLH group (WMD 22min; 95% CI 5–39min; p =0.01). Rates of major complication were not statistically different (pooled OR 1.35; 95% CI 0.32–5.73) though this analysis is likely underpowered to detect many major complications. As such, TLH appears to offer benefits to women requiring total hysterectomy for benign indications compared to TAH, particularly regarding minor complications, blood loss and hospital stay. However, larger studies are needed to assess the impact on major intra-operative complications and long-term clinical outcomes, particularly pelvic organ prolapse. [Copyright &y& Elsevier]

Abstract: Objective: Hysterectomy represents one of the most performed procedures in gynecological surgery. The minimally invasive approach increases patients’ benefits and reduces hospitalization costs. The aim of this study was to demonstrate the efficacy and safety of double barbed suture in vaginal cuff closure during total laparoscopic hysterectomy. Study design: A retrospective cohort study of 88 consecutive patients treated with total laparoscopic hysterectomy for benign or precancerous conditions was undertaken from January 2010 to December 2011. Vaginal cuff suture was performed with traditional interrupted suture with polycolic acid (Vicryl™) in 40 patients and with bidirectional barbed device, Quill SRS™, in 48 patients. Results: No difference in vaginal cuff dehiscence, major vaginal bleeding or spotting, and infection was evident between the two groups, with significant reduction in operative times for the bidirectional barbed suture group. Conclusion: Vaginal cuff suture performed with bidirectional barbed QUILL SRS™ is a safe and well-tolerated procedure that reduces operative times. [Copyright &y& Elsevier]