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Objective: To evaluate the safety and feasibility of the new surgical robot HUGO robotic assisted surgery (RAS) in a series of gynecologic surgical procedures. Methods: Between March and October 2022, 138 patients treated at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy were enrolled in the study. All patients suitable for a minimally‐invasive approach were prospectively included and divided into two groups: Group 1 (78 patients) made up of patients operated on for uterine and/or adnexal pathologies, and Group 2 (60 patients) made up of patients treated for pelvic organ prolapse. Results: In Group 1, median docking time (DT) was 5 min and median console time (CT) was 90 min. In two patients (2.6%) redocking was necessary. In two patients (2.6%), the surgeon continued the surgery laparoscopically. Intraoperative complications occurred in two surgeries (2.6%). In Group 2, median DT was 4 min and median CT was 134.5 min. In three patients (5%), redocking was necessary. In all patients, the surgery was successfully completed robotically without intraoperative complications. Conclusions: The present study demonstrates that the new HUGO RAS system for gynecologic surgery is safe with good results in terms of surgical efficacy and perioperative outcomes. Further studies are needed to investigate its use in other technical and surgical aspects. Synopsis: The new robotic system HUGO RAS is safe with good results in terms of surgical efficacy and perioperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Premature ovarian failure may be a consequence of radiotherapy administered for the treatment of various female oncologic diseases. Before radiotherapy, fertility may be preserved through ovarian transposition (OT), which consists of moving the ovaries away from the radiation field. Objective: To ascertain all types of surgical techniques employed for OT, outline the endocrine and reproductive outcomes of each one, and discover if one works better than the others. Search strategy: The authors performed a systematic search of the English literature looking for all studies related to OT before radiotherapy published up to June 2023. Nine studies were included. Selection criteria: The eligible studies were assessed based on the presence of a description of the surgical technique employed for OT before pelvic radiotherapy and a report of the endocrine and reproductive outcomes. Data collection and analysis: Odds ratios (OR) with 95% confidence intervals were used to compare endocrine and reproductive outcomes The χ2 test was employed for the statistical analysis and a P value less than 0.05 was considered significant. Main results: A total of 323 female patients aged between 7 and 51 years—198 (61.3%) with non‐gynecologic cancer and 125 (38.7%) with gynecologic cancer—underwent OT, either bilateral (221, 68.4%) or unilateral (102, 31.6%), before radiotherapy. Essentially, two types of OT were employed: lateral and medial. A total of 71 (22%) patients underwent medial OT and 252 (78%) patients (127 with non‐gynecologic tumors and 125 with gynecologic tumors) had a lateral OT. The latter was used in a similar percentage of cases for gynecologic (50.4%) and non‐gynecologic (49.6%) tumors, whereas the medial approach was performed only for non‐gynecologic cancers (Hodgkin's lymphoma). The difference between medial OT and lateral OT was not significant regarding the preservation of endocrine function (OR 0.65, P = 0.120). However, midline OT worked better in terms of reproductive outcomes. In fact, the percentage of patients with pregnancy (49.2%) and live births (45%) associated with medial OT was significantly higher than that associated with lateral OT, 6.5% and 13.4%, respectively, and the difference between such data was statistically significant (OR 7.04, P = 0.001 and OR 5.29, P = 0.003, respectively). Conclusions: Ovarian transposition is an important method to preserve fertility before radiotherapy, considering the worldwide ongoing use of this treatment for various cancers arising in young women. The surgical method depends on the type of disease, but OT—especially medial OT when feasible—is effective in terms of ovarian function preservation and reproductive outcomes. Synopsis: The difference in endocrine function preservation between medial and lateral ovarian transposition was not significant, but midline ovarian transposition yielded better reproductive outcomes. [ABSTRACT FROM AUTHOR]

Uterus didelphys is a rare Müllerian anomaly, often diagnosed during menarche or in women with a personal history of infertility and/or recurrent pregnancy loss. Its association with other genitourinary anomalies is frequent and may determine the existence of established syndromes. This case report refers to a 13‐year‐old female patient diagnosed with OHVIRA syndrome (Obstructed Hemivagina with Ipsilateral Renal Agenesis), a condition wherein the presence of a didelphic uterus is associated with hemivagina obstruction and ipsilateral renal agenesis. The patient presented with cyclic pelvic pain, related to the presence of hematocolpos and hematometra, which persisted despite several surgical approaches, including vaginal septum excision and correction of cervical stenosis. The recurrence of the condition indicated exploratory laparotomy, revealing two hemi‐uteri and two uterine cervixes, with hematometra on the right. A subtotal hemihysterectomy was performed on the right. Post‐procedure, the patient developed with regular menstrual cycles and improvement of pelvic pain complaints. Given the limited prevalence and low index of suspicion, the potential requirement for surgical intervention and its potential impact on reproductive future, diagnosing and treating OHVIRA syndrome and other Müllerian anomalies poses notable challenges in clinical practice. Hence, sharing different therapeutic approaches of a rare diagnosis with the scientific community is of paramount importance to aid in early diagnosis and effective management of similar clinical cases. Synopsis: A case report of a patient with obstructed hemivagina with ipsilateral renal agenesis syndrome supports hemihysterectomy as a potential therapeutic approach in refractory cases. [ABSTRACT FROM AUTHOR]

Chronic, severe Crohn's disease in a young female patient can result in surgical complexity. The rarity of the presentation of intractable pelvic abscesses within this etiology with additional considerations given to fertility concerns and hence requirement for input from a multi‐disciplinary team makes this a vital case in building a consensus for evidence‐based surgical management. A 29‐year‐old nulliparous woman was referred to our tertiary centre for surgical management of Crohn's disease with known tubo‐ovarian abscess and abdominoperineal and abdominal wall sinuses. Her previous surgical history included 4 midline laparotomies, subtotal colectomy and proctectomy with stoma formation. The patient underwent egg collection to preserve fertility. This was followed by midline laparotomy and abdominoperineal resection, which involved a retrograde radical modified hysterectomy using the Hudson technique, alongside excision of the perineal sinus, with reconstruction of the perineal defect using an internal pudendal artery perforator gluteal fold flap, and in addition to excision and drainage of the abdominal wall abscess. Involvement was sought from gynecological oncology, colorectal, urology, plastics, stoma, fertility, microbiology, and gastroenterology teams, which enabled successful preservation of end organ function and improvement in patient psychological well‐being. This case is a paradigm of surgical challenge, requiring expert gynecological oncology techniques including a retroperitoneal approach, nerve and vessel sparing considerations alongside colorectal and urological procedures. Moreover, we believe that our blueprint for effective multi‐disciplinary practice will inform the future management of gynecological surgery. Therefore this report aims to contribute towards the optimum management of the gynecological sequelae of Crohn's disease. Synopsis: We detail the surgical management of a young female with tubo‐ovarian abscess complications of Crohn's disease and the evidence‐based management undertaken by our tertiary center. [ABSTRACT FROM AUTHOR]

Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age‐related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk–benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post‐surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether abdominal hot water pack application improves gastrointestinal motility following gynecological oncology surgery. Methods: The study was registered at ClinicalTrials.gov (NCT04833699). (https://clinicaltrials.gov/ct2/show/NCT04833699?cond=NCT04833699&draw=2&rank=1). In this randomized controlled trial, participants were randomly assigned (1:1) to the hot water pack group (standardized enhanced recovery protocols plus rubber water bag with a fluffy cover filled with boiled tap water [80°C] and placed on the abdomen at 3, 6, 9, and 12 h postoperatively for 30 min each time) or the control group (standardized enhanced recovery protocols). A subumbilical or supraumbilical vertical midline incision was made to perform staging surgery procedures, including hysterectomy, salpingo‐oophorectomy with retroperitoneal lymphadenectomy. The primary outcome was the time to first passage of flatus from the end of the staging procedure. Results: In total, 121 women were randomized to the control (n = 62) or hot water pack (n = 59) group. The use of an abdominal hot water pack significantly reduced the mean time to passing first flatus (25.2 ± 3.6 vs. 30.6 ± 3.9 h; hazard ratio [HR] = 4.4; 95% confidence interval [CI]: 2.8–7.1; P < 0.0001), mean time to first bowel movements (28.4 ± 4.0 vs. 34.4 ± 4.5 h; HR = 4.9; 95% CI: 3.0–7.9; P < 0.0001), mean time to first defecation (33.4 ± 4.9 vs. 41.0 ± 7.6 h; HR = 4.3; 95% CI: 2.1–6.8; P < 0.0001), and mean time to tolerating solid diet (2.1 ± 0.6 vs. 2.8 ± 1.0 days; HR = 4.4; 95% CI: 2.2–8.7; P < 0.0001) compared to the control group. The postoperative ileus incidence was significantly lower in the hot water pack group (3.4%) than the control group (16.1%) (P = 0.01). Conclusion: Abdominal hot water pack application improved gastrointestinal function recovery in women following surgical staging procedures for gynecological malignancy. Synopsis: An abdominal hot water pack significantly reduced postoperative ileus and corresponding medical costs; early hospital discharge was feasible. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field. Methods: A single‐center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non‐involvement groups. The primary endpoint was the 30‐day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non‐involvement. Results: Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30‐day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non‐involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non‐involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68–23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01–1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00–1.00; P < 0.001) were significantly associated with 30‐day morbidity, but resident involvement was not statistically significant. Conclusion: There was no significant difference in the 30‐day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety. Synopsis: Trainee involvement in hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate intraoperative factors predicting appendiceal pathology during gynecologic oncology surgery for suspected mucinous ovarian neoplasms. Methods: We conducted a retrospective study on 225 patients with mucinous ovarian neoplasms who underwent surgery for an adnexal mass with concurrent appendectomy between 2000 and 2018. Regression analyses were used to evaluate intraoperative factors, such as frozen section of the ovarian mass and surgeon's impression of the appendix in predicting appendiceal pathology. Results: Most patients (77.8%) had a normal appendix on final pathology. Abnormal appendix cases (n = 26) included: metastasis from high‐grade adenocarcinoma of the ovary (n = 1), neuroendocrine tumor of the appendix (n = 4), and low‐grade appendiceal mucinous neoplasms (n = 26; 23 associated with a mucinous ovarian adenocarcinoma, 2 with a benign mucinous ovarian cystadenoma, and 1 with a borderline mucinous ovarian tumor). Combining normal intraoperative appearance of the appendix with benign or borderline frozen section yielded a negative predictive value of 85.1%, with 14.9% of patients being misclassified, and 6.0% having a neuroendocrine tumor or low‐grade appendiceal neoplasm. Conclusion: Benign or borderline frozen section of an ovarian mucinous neoplasm and normal appearing appendix have limited predictive value for appendiceal pathology. Appendectomy with removal of the mesoappendix should be considered in all cases of mucinous ovarian neoplasm, regardless of intraoperative findings. Synopsis: The false‐negative rate for normal appearing appendix with benign/borderline ovarian frozen section is 6% and as high as 15% with reassuring intraoperative factors. [ABSTRACT FROM AUTHOR]

Objective: To compare prebundle versus postbundle implementation urinary tract infection (UTI) rates among inpatients within 6 weeks of clean‐contaminated pelvic reconstructive surgery. Methods: The authors conducted a retrospective cohort study from September 2019 to December 2021 at a tertiary hospital. The bundle strategy included the following: universal preoperative UTI check with treatment if positive, replacing prolonged postoperative voiding trials on the ward with earlier discharge and indwelling catheter removal by a nurse continence advisor the next day, and daily cranberry extract for 6 weeks postoperatively. UTI was defined as positive urine culture (≥100 000 colony‐forming unit per mL) in a symptomatic patient. Data analysis involved hypothesis testing and logistic regression. Results: The authors reviewed 132 postbundle inpatient charts and retained 93 for analyses. The results were compared with 204 prebundle inpatient charts. The rate of postoperative UTI decreased from 17.6% in the prebundle group to 6.5% after bundle implementation (P = 0.01). The adjusted odds ratio for postbundle versus prebundle likelihood of UTI was 0.35 (95% confidence interval, 0.13–0.98; P = 0.045). Significantly more postbundle patients compared with prebundle patients were discharged home on the first day postoperatively (76.3% vs. 37.7%, P < 0.001). Conclusions: A clinical bundle can significantly decrease both UTI rates and hospital stay after pelvic reconstructive surgery. Synopsis: We introduced a bundle strategy to prevent urinary tract infections after inpatient urogynecologic surgery. We conducted a retrospective cohort study to compare prebundle versus postbundle urinary tract infection rates. [ABSTRACT FROM AUTHOR]

Objective: To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions. Methods: We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min. Results: According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false‐negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%. Conclusions: Ultrasound with power Doppler represents an effective and reliable non‐invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy. Synopsis: Power Doppler ultrasound represents an effective and reliable non‐invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy. [ABSTRACT FROM AUTHOR]

Synopsis: Uteroenteric fistulae in the setting of degenerating leiomyomas may present with small bowel obstruction and require multidisciplinary surgical management to perform fertility‐sparing myomectomy. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was three‐fold. One, to assess the prevalence of medical traumatization in outpatients of a gynecologic department; two, to analyze the relationship of medical traumatization with adverse childhood events; and three, to investigate the extent to which medical traumatization affects the health outcomes of woman. Methods: Between January and September 2022, a prospective cross‐sectional study recruited patients of a gynecologic outpatient clinic at St. Gallen Cantonal Hospital in Switzerland. Medical trauma was a self‐reported item. The presence of adverse childhood events was assessed using the Childhood Trauma Questionnaire. The severity of post‐traumatic stress was evaluated using the Impact of Event Scale Revised questionnaire. Results: In total, 227 patients were recruited. Medical trauma was reported by 20% of the interviewees and it was strongly associated with obesity (A = 0.005). Undergoing surgery was most commonly the source of psychological distress (5.7%) followed by delivery (4.8%), pregnancy loss (4.8%), and cancer diagnosis (4.0%). Yet, fewer than 1% of the patients reached the threshold suggesting post‐traumatic stress disorder. Conclusions: We found no relationship between the medical trauma, adverse childhood events, cardiovascular disease, or substance abuse. The presence of medical trauma was associated with the patient's body mass index (calculated as weight in kilograms divided by the square of height in meters). Synopsis: We found that one in five women in our population reported having a medical psychological trauma. Its presence was associated with the patient's BMI. [ABSTRACT FROM AUTHOR]

Objective: To compare the perioperative outcomes of patients undergoing abdominal hysterectomies for leiomyomas before and after the implementation of an enhanced recovery after surgery (ERAS) protocol in a teaching hospital. Methods: This prospective cohort study compared a patient group from a historical series (pre‐ERAS) with another group after ERAS implementation. Fasting time, length of hospital stay, complications, readmission rates, and procedure‐related hospital costs were analyzed. Results: Altogether, 187 patients were included in the analysis: 92 (49.2%) and 95 (50.8%) in the pre‐ERAS and ERAS groups, respectively. Both groups had similar clinical characteristics. We observed reductions in surgical outcome findings: fasting time (13.9 to 6.7 h, P < 0.001), bladder catheter usage (21.1 to 10.9 h, P < 0.001), infection rates (20.7% to 5.3%, P = 0.002), length of stay (57.5 to 37.6 h), and 38.4% of the total estimated mean cost per procedure (USD $1570.8 to USD $967.2, P < 0.001) in the pre‐ERAS and ERAS groups, respectively. Hospital readmission rates (P > 0.99) did not increase. Conclusion: ERAS protocol implementation for hysterectomies involving uterine leiomyomas reduced the length of hospital stay, surgical site infection rates, and hospital costs. A mean savings of USD $603.6 per procedure would allow 62.4% more hysterectomies to be performed. Synopsis: The modified enhanced recovery after surgery protocol for gynecological surgery reduced the length of hospital stay, the surgical site infection rate, and overall hospital costs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate how hysterectomy performed for benign gynecologic pathologies affects the quality of life and sexual function of patients aged 35 years or younger, and if outcomes differ according to the surgical technique. Methods: Seventy‐three patients who underwent total laparoscopic hysterectomy (TLH), supracervical laparoscopic hysterectomy (SLH), or vaginal hysterectomy (VH) for benign uterine disorders between April 2014 and June 2020 at the Department of Gynecology and Obstetrics, Saarland University Hospital, Homburg, Germany, were enrolled in this prospective observational cohort study. Quality of life and sexual function were assessed preoperatively and 6 months postoperatively using standardized validated questionnaires: the European Quality of Life Five‐Dimension Scale (EQ‐5D) and the Female Sexual Function Index (FSFI). Results: Thirty‐three (45%) patients underwent TLH, 25 (34%) underwent SLH, and 15 (21%) patients underwent VH. The median preoperative EQ‐5D score, FSFI score, and EQ‐5D visual analog scale were 0.9 (range 0.62–1), 19.25 (range 2.4–27.4), and 50 (range 0–100); postoperative scores were 1 (range 0.61–1), 24.15 (range 3.9–29.3), and 90 (range 30–100), respectively (P ≤ 0.001). Postoperative scores were significantly higher than preoperative scores, with no significant difference according to the surgical technique. Conclusion: Hysterectomy for benign indication in women aged 35 years or less significantly improved the patients' quality of life and sexual function with no differences regarding the surgical technique. Clinical trial registration: The study was registered in the German trial registry (no. DRKS00005622). Synopsis: Hysterectomy for benign indication in women up to 35 years significantly improved their quality of life and sexual function with no differences for surgical technique. [ABSTRACT FROM AUTHOR]

Objective: To acquire a comprehensive assessment of the current status of implementation of Enhanced Recovery After Surgery (ERAS) protocols across Europe. Methods: The survey was launched by The European Network of Young Gynecologic Oncologists (ENYGO). A 45‐item survey was disseminated online through the European Society of Gynecological Oncology (ESGO) Network database. Results: A total of 116 ESGO centers participated in the survey between December 2020 and June 2021. Overall, 80 (70%) centers reported that ERAS was implemented at their institution: 63% reported a length of stay (LOS) for advanced ovarian cancer surgery between 5 and 7 days; 57 (81%) centers reported a LOS between 2 and 4 days in patients who underwent an early‐stage gynecologic cancer surgery. The ERAS items with high reported compliance (>75% "normally‐always") included deep vein thrombosis prophylaxis (89%), antibiotic prophylaxis (79%), prevention of hypothermia (55%), and early mobilization (55%). The ERAS items that were poorly adhered to (less than 50%) included early removal of urinary catheter (33%), and avoidance of drains (25%). Conclusion: This survey shows broad implementation of ERAS protocols across Europe; however, a wide variation in adherence to the various ERAS protocol items was reported. Synopsis: There is broad implementation of the ERAS protocols across European centers, but a wide variation in adherence to the various ERAS protocol items was reported. [ABSTRACT FROM AUTHOR]

Objective: To analyze outcomes and postoperative complications in patients undergoing robot‐assisted isthmocele repair. Method: This retrospective cohort study included 33 patients who had robot‐assisted laparoscopic surgical management of an isthmocele between September 2013 and August 2020 in two French university hospitals. All charts were reviewed to identify patient characteristics, preoperative and postoperative anatomical findings, complications, and postoperative fertility and symptoms. Patients who had undergone this procedure were asked to complete a telephone questionnaire about their treatment satisfaction and symptoms. Results: The isthmocele was discovered most often as a result of subfertility (57.6%), but also ectopic pregnancy (18.2%), pelvic pain (15.2%), and postmenstrual bleeding (9.1%). Robot‐assisted repair of the isthmocele significantly improved myometrial thickness (from 1.55 mm before surgery to 4.26 mm after surgery [mean difference 2.71; 95% confidence interval, 1.91–3.51], P = 0.0005). Among 20 patients who still desired a child after surgery, 15 became pregnant and 14 had full‐term live births. Among the nine patients who had surgery for disabling symptoms, five had no persistent symptoms, three reported global improvement, and one had the same gynecologic discomfort. Seventeen patients agreed to complete the questionnaires (51.5%), and all stated that they would choose to have this surgery again. Conclusion: Robot‐assisted repair of an isthmocele is a viable minimally invasive procedure. Synopsis: Robot‐assisted repair of an isthmocele, while not standardized, is a viable minimally invasive procedure for women with an isthmocele and symptoms, and improves subfertility. [ABSTRACT FROM AUTHOR]

Background: The proper time for removing the urinary catheter after gynecologic laparoscopy is unclear. Objectives: To assess the feasibility of immediate catheter removal after benign gynecologic laparoscopy. Search Strategy: PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Wanfang Data were searched from inception to November 30, 2021. Selection Criteria: Only randomized controlled trials published in English or Chinese comparing immediate versus delayed catheter removal after gynecologic laparoscopy for benign diseases were included. Data Collection and Analysis: The primary outcome was the incidence of postoperative urinary retention (PUR). A random effects model was used to calculate pooled relative risk (RR) and 95% confidence interval (CI). Main Results: Six studies were included in this meta‐analysis. There was no significant difference in PUR between immediate and delayed catheter removal (RR 1.51, 95% CI 0.37–6.18), but the evidence was of very low quality. Subgroup analysis according to the type of surgery showed a higher rate of PUR with immediate removal after hysterectomy than after other surgeries. Immediate removal was associated a lower incidence of urinary tract infection and a shorter time to mobilization compared with delayed removal. Conclusions: Immediate removal of the urinary catheter is feasible and beneficial after benign gynecologic laparoscopy. Synopsis: Immediate removal of the urinary catheter is feasible and beneficial after uncomplicated gynecologic laparoscopy, especially for minor surgeries excluding hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To examine the effectiveness of applying the recommended enhanced recovery after surgery (ERAS) protocol compared with our usual care in women with gynecologic malignancy undergoing elective laparotomy. Methods: From June 2020 to May 2021, 93 women with gynecologic cancers (cervix, endometrium, and ovary) undergoing elective laparotomy at our institution were randomly assigned into an intervention group (ERAS protocol, 46 women) or control group (usual care, 47 women). For the intervention group, each woman was brought through the pre‐specified ERAS protocol starting from preoperative counseling to postoperative management. For the control group, participants underwent routine standard care. The primary outcomes were length of hospital stay and postoperative pain. Results: The intervention group demonstrated shorter hospital stay by 20 h (47.48 h vs 67.17 h, P = 0.02) with lower postoperative pain score at postoperative day 0 (1.58 vs 4.00, P < 0.01) and day 1 (1.00 vs 2.67, P < 0.01) while having decreased opioid consumption (P < 0.01). The intervention group also had faster recovery of gastrointestinal function. Overall, good compliance to most of the ERAS pathway domains was obtained. Conclusion: The ERAS protocol demonstrates benefits on shortening hospital stay, reducing pain, and bowel function recovery without increasing complications in our population. Clinical Trial Registration: The present study was registered at clinicaltrials.gov (NCT04201626) on December 3, 2019. Initial participant enrollment began on June 1, 2020. Access through URL of the registration site: https://clinicaltrials.gov/ct2/show/NCT04201626?cond=ERAS&cntry=TH&draw=2&rank=3. Synopsis: The contents of this page will be used as part of issue TOC only. It will not be published as part of main article.The enhanced recovery after surgery protocol was associated with shorter hospital stay, lower postoperative pain scores, less narcotic consumption, faster return of gastrointestinal function, and potentially improved mobility. [ABSTRACT FROM AUTHOR]

Objective: To describe the risk factors for immediate failure of gynecologic outpatient surgery. The secondary objective was to describe the risk factors for rehospitalization within 30 days after surgery. Methods: This is a single‐center retrospective cohort study conducted on all patients operated on in outpatient surgery in gynecology at the Lille University Hospital. The primary outcome was defined as any unanticipated admission to the inpatient postoperative care unit on the day of the operation. The secondary outcome was defined as any rehospitalization within 30 days following the intervention. Our statistical analysis included 916 patients operated on between January and July 2019. Results: In our study, 84 patients (9.2%) had an immediate failure of outpatient surgery. The most frequent etiologies were surgical (58.3%). In multivariate analysis with logistic regression, the following variables were associated with an increased risk of immediate failure of outpatient surgery: urogynecologic surgery (P < 0.001), complex laparoscopy (P = 0.004), endometriosis surgery (P < 0.001), and a duration of intervention longer than 1 hour (P < 0.001). Conclusion: We find an increased risk of immediate failure of gynecologic outpatient surgery depending on the type of surgery as well as for surgeries lasting more than 1 hour. Synopsis: Risk of immediate failure of outpatient gynecologic surgery for urogynecology, endometriosis, and complex laparoscopy is increased in interventions of more than 1 hour. [ABSTRACT FROM AUTHOR]

Objective: To assess and compare the health‐related quality of life of women undergoing robotic gynecologic surgery, laparoscopic gynecologic surgery or laparotomy for benign and cancerous conditions. Methods: Cross‐sectional study design was used. The present study was carried out with 240 women, who underwent gynecologic surgery (robotic 48, laparoscopic 96, and laparotomy 96) in a tertiary care hospital. Instruments included a participant description questionnaire and Medical Outcomes Study Short Form‐36. The data were collected 4 weeks after surgery, at the first postoperative visit of women to the clinic. Pearson χ2 test, one‐way analysis of variance, and regression analysis were used to assess the data. Results: Over half of the women in each group had surgery because of gynecologic cancer. All the subscale scores of Medical Outcomes Study Short Form‐36 were significantly higher in the robotic group than the other surgical groups (P < 0.05). Women in the robotic group had better quality of life in terms of both the physical component and the mental component after surgery. Conclusions: Knowledge of health‐related quality of life in the recovery period after surgery is important for healthcare providers to provide adequate preventive measures, information, and follow up. [ABSTRACT FROM AUTHOR]

Objective: To investigate the clinical course and management of abdominal wall endometriosis (AWE). Methods: A retrospective study was carried out from January 2010 to December 2020, at Vita‐Nações Hospitals, Curitiba, Brazil, in order to evaluate data of patients undergoing surgery for the excision of AWE. Results: 83 women with AWE were included in the study. Umbilical scar endometriosis was found in 26 patients (31.3%), being primary in 20 cases (76.9%) and secondary to a laparoscopic procedure in 6 cases (23.1%). 2 patients had secondary implants outside the umbilicus after laparoscopic surgery. Secondary implant after cesarian section in 55 patients (66.3%). Diagnosis was made by ultrasound in 65 patients (78.3%) and by MRI in the remaining 18 (21.7%). Complete excision of the nodule was carried out and no case of recurrence was registered up to now. Conclusions: Painful abdominal mass presenting in women, especially with a previous history of abdominal and pelvic surgery, should be suspected of AWE. It occurs most often secondary to obstetric or gynecological surgeries and seems to be related to iatrogenic transfer of the endometrial tissue at the level of the surgical scar. Cesarean scar endometriosis is the most common presentation. Surgical excision including the surrounding fibrotic tissue should be performed. Abdominal wall endometriosis is a rare and uncommon presentation of endometriosis and it occurs most often secondary to obstetric or gynecological surgeries. [ABSTRACT FROM AUTHOR]

Objective: To explore whether patient characteristics were associated with gender expression, and to further determine impact of gender expression on patient selection of hysterectomy or uterine‐preservation in pelvic organ prolapse (POP) surgery. Methods: Within a prospective cohort, a self‐reported gender expression tool classified patients as expressing gender polar (i.e., reporting only feminine traits) or non‐polar gender scores (i.e., reporting feminine and masculine traits). Multivariate modeling explored associations of gender expression with traditional socio‐demographic variables, and with selection of hysterectomy or uterine‐preserving surgery. Descriptive statistics of socio‐demographic variables were reported by frequency, proportion and mean (SD). Results: 177 participants completed the gender score questionnaire. Overall, the sample had a more feminine gender expression with the majority of respondents classified as gender polar (67.23%, n = 119). Participants with non‐polar gender scores were 2.53 times (95% 1.05–6.09) more likely to choose uterine preservation versus hysterectomy‐based surgery. Gender polarity was weakly associated with age, but no other sociodemographic variables. Conclusion: Gender expression is not tightly associated with socio‐demographic variables, and is thus a novel measurement in gynecologic research. Gender polarity appears to be associated with choice to undergo hysterectomy. Further research is required to understand this relationship and implications in clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the American College of Surgeons (ACS) surgical risk calculator's reliability in predicting outcomes in hysterectomies. Methods: This is a prospective cohort study at a large community‐based hospital. Twenty‐one preoperative and postoperative criteria were abstracted from the electronic medical record and entered into the online ACS calculator to determine a risk score. Logistical regression was used to determine the association between risk score and actual outcome. The prediction capability was analyzed with c‐statistic, Hosmer‐Lemeshow, and Brier score. Results: A total of 634 hysterectomies were performed during the study period from January to April 2019. Patients were predominantly 55 years old, white (53%) and overweight (body mass index 30). Predicted perioperative adverse events were significantly higher than actual adverse events across all domains. In all, 54/634 (8.5%) patients experienced postoperative urinary tract infection. C‐statistics for return to operating room, renal failure, and readmission were 0.607 (95% C Statistic index [CI] 0.370–0.845), 0.882 (95% CI 0.802–0.962), 0.637 (95% CI 0.524–0.750), respectively. Brier scores approached one in all categorical domains. Conclusion: The ACS surgical risk calculator holds the promise of predicting postoperative complications or length of stay for patients undergoing hysterectomy. Further adjustment to this tool is required before it can be advocated for use in the clinical setting. The ACS NSQIP surgical risk calculator is a moderate predictive tool for postoperative complications for patients undergoing hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: EnPlace™ (formerly named NeuGuide™) is a minimally invasive meshless anchoring system for pelvic organ prolapse (POP) repair designed to provide centro-apical pelvic floor support. We present a 4-year prospective follow up evaluation of this repair system.Methods: This was a single-center longitudinal prospective study of women with advanced POP who underwent pelvic floor apical repair using EnPlace™ with at least 4 years of follow-up. The primary outcome was surgical success defined as anatomical success, no symptoms of vaginal bulging and no need for re-treatment. A standardized validated questionnaire to assess symptom burden was used.Results: Fifteen women were enrolled in the study. Two patients were lost to follow-up. The median follow-up was 51 months (range 42-57) with a surgical success rate of 92.3%. One patient (7.7%) reported symptoms of vaginal vault prolapse and underwent a repeated prolapse surgery. Using the UDI-6 questionnaire, an improvement in all domains was seen.Conclusion: The 4-year prospective follow up suggests that apical repair using the EnPlace™ device may be considered safe and effective for sacrospinous ligament fixation with a sustainable long-term success. This procedure is a minimally invasive meshless addition to pelvic surgeon's armamentarium. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of ramosetron after gynecological laparoscopic surgery on the recovery of bowel function. Methods: A prospective randomized controlled trial conducted at Kyung Hee University hospital, South Korea, from August 2016 to September 2017. Patients were randomized to receive either 10 mg dexamethasone before induction of anesthesia (control group C), followed by intravenous administration of patient-controlled analgesia (IV-PCA) or 2 ml normal saline before induction of anesthesia and 0.6 mg ramosetron (study group R) administered with IV-PCA. Results: A total of 88 patients were enrolled. Times to first flatus (group C 23.98 ± 6.31 vs. group R 27.14 ± 9.56 h; P = 0.148) and first defecation (group C 36.16 ± 16.04 vs. group R 43.41 ± 20.01 h; P = 0.138) showed no statistically significant differences. No significant differences were observed in the frequency of postoperative nausea and vomiting (PONV) and demand for additional analgesics. Multiple linear regression for analysis of factors affecting time to first flatus revealed no significant results. Conclusion: Ramosetron did not delay bowel movement recovery after gynecologic laparoscopic surgery and was as effective as dexamethasone in regulating PONV. Ramosetron can be used with IV- PCA without concerns about delay in recovery of bowel function. Clini calTr ials.gov registration number: NCT02849483. [ABSTRACT FROM AUTHOR]

Synopsis: Reproductive surgery is a distinct form of gynecologic surgery. Instead of eradicating the disease, reproductive surgery is intended to maintain or treat fertility. [ABSTRACT FROM AUTHOR]

Synopsis: The novel use of an Ellick bladder evacuator for tissue retrieval after operative hysteroscopy by electrosurgical resectoscope can reduce operative time, multiple additional scope reinsertions and possible complications. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the incidence of occult uterine sarcomas and investigate whether an accurate and well‐established preoperative assessment for uterine fibroids could help identify uterine sarcomas more effectively. Methods: A retrospective analysis of patients who underwent gynecological laparoscopic surgery for presumed uterine fibroids at Sant'Anna Hospital, a single tertiary institute in Turin, Italy, between January 2003 and December 2019. Results: Over the 17‐year period, 5826 laparoscopic surgical procedures (myomectomies or subtotal/total hysterectomies) were performed for presumed uterine fibroids. A total of 48 patients with a final diagnosis of uterine sarcoma were identified, the majority of which (n = 39; 81.3%) were recognized as suspicious uterine sarcomas during the preoperative assessment, and morcellement was avoided. The occurrence of unexpected uterine sarcomas was 0.1% (6/5826). Morcellation was conducted in one patient with uterine sarcoma. Conclusion: Analysis of our data showed that unexpected uterine sarcomas are uncommon. Accurate preoperative evaluation can help avoid, but does not exclude, the possibility of morcellation of unknown uterine sarcomas. Data analysis showed that unexpected uterine sarcomas are uncommon. Accurate preoperative evaluation can help avoid, but does not exclude, the possibility of morcellation of unknown uterine sarcomas. [ABSTRACT FROM AUTHOR]

Objective: To explore the ability of albumin concentration to predict calf venous thromboembolism (cVTE) in gynecologic diseases. Methods: We analyzed data from 761 patients from the gynecology department. We screened the serum albumin concentration as an important indicator for predicting cVTE through logistic analysis. The data were divided into albumin below 35 and 35 g/L or more. Receiver operating characteristics analysis was used to compare the predictive ability of albumin, D‐dimer, and a combination of these parameters as indicators for cVTE risk in different groups and subgroups. Results: In gynecologic diseases, the albumin concentrations were lower in the surgery and malignancy group than in the chemotherapy and benign disease group. Albumin concentration had a predictive ability for cVTE risk. In ovarian cancer patients with albumin concentrations less than 35 g/L, albumin was better than D‐dimer at predicting cVTE (area under the curve [AUC] 0.79, 95% confidence interval [CI] 0.70–0.87, P < 0.001 versus AUC 0.65, 95% CI 0.54–0.77, P = 0.016). Conclusion: The albumin concentration was a candidate indicator for predicting cVTE in surgical patients in the gynecology department, especially in ovarian cancer patients with albumin concentrations less than 35 g/L. A combination of the albumin and D‐dimer parameters may improve the predictive ability for cVTE. Synopsis: Low albumin concentration is a risk factor for calf venous thromboembolism (cVTE) in gynecologic diseases; albumin concentration can be used as an indicator for predicting cVTE. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the role of appendectomy in surgical excision of endometriosis and to assess complications associated with appendectomy. Methods: Retrospective study of women undergoing appendectomy for pelvic pain and/or endometriosis during a primary gynecologic procedure. Results: Record review was performed for 609 women who underwent appendectomy between 2013 and 2019 for pelvic pain (6.9%, 42/609), stage I–II endometriosis (63.7%, 388/609), or stage III–IV endometriosis (29.4%, 179/609). Appendiceal endometriosis (AppE) was present in 14.9% (91/609); 2.4% without endometriosis (1/42, reference group), 7.0% with stage I–II endometriosis (27/388, odds ratio [OR] 3.06, 95% confidence interval [CI] 0.41–23.11, P = 0.278), and 35.2% with stage III–IV endometriosis (63/179, OR 22.24, 95% CI 2.99–165.40, P = 0.002). AppE was significantly associated with endometriosis present in other locations (OR 5.27, 95% CI 2.66–10.43, P < 0.001). The predicted probability of identifying AppE ranged from 6% with 0 positive endometriosis sites to 56% when 4 or more sites were identified. There were no complications related to the performance of an appendectomy. Conclusion: Women with chronic pelvic pain and/or endometriosis have an increased risk of AppE. Modern appendectomy at the time of gynecologic surgery is safe, with no associated complications in this study. Our findings support the consideration of appendectomy as part of the comprehensive surgical management of endometriosis. Synopsis: Appendiceal endometriosis occurs in 14.9% of women undergoing laparoscopic surgery for chronic pelvic pain/endometriosis. As such, opportunistic appendectomy should be considered in this patient population. [ABSTRACT FROM AUTHOR]

Synopsis: Mixed reality is useful for assessing the location of uterine fibroids during laparoscopic myomectomy, potentially reducing recurrence of fibroid remnants and improving quality of life. [ABSTRACT FROM AUTHOR]

Surgery can continue safely during the pandemic in a specialty hospital that does not accept COVID‐19‐positive patients. [ABSTRACT FROM AUTHOR]

Objective: To report the perioperative outcomes of 200 patients with gynecologic cancer who underwent surgery during the Novel Coronavirus Disease (COVID-19) pandemic and the safety of surgical approach.Methods: Data of patients operated between March 10 and May 20, 2020, were collected retrospectively. Data were statistically analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows v. SP21.0.Results: Data of 200 patients were included. Their mean age was 56 years. Of the patients, 54% (n=108), 27.5% (n=55), 12.5% (n=25), and 2% (n=4) were diagnosed as having endometrial, ovarian, cervical, and vulvar cancer, respectively. Of them, 98% underwent non-emergent surgery. A minimally invasive surgical approach was used in 18%. Stage 1 cancer was found in 68% of patients. Surgeons reported COVID-related changes in 10% of the cases. The rate of postoperative complications was 12%. Only two patients had cough and suspected pneumonic lesions on thoracic computed tomography postoperatively, but neither was positive for COVID-19 on polymerase chain reaction testing.Conclusion: Based on the present findings, it is thought that gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to the measures. Postponement or non-surgical management should only be considered in patients with documented infection. Gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to measures. Only 1% of patients developed COVID-19-related symptoms during the postoperative follow-up period. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders.Methods: A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications.Results: Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P<0.001). Estimated blood loss was similar (1874 ± 245 mL vs 1713 ± 181 mL, P=0.590).Conclusion: Women undergoing prophylactic placement of endovascular balloons at caesarean hysterectomy for PAS disorders had a 10.6% procedure-related complication rate and increased total procedure time, with no decrease in blood loss compared to those undergoing surgical ligation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of a surgical site infection (SSI) prevention bundle on SSI rates after hysterectomy for benign and malignant indications at an urban academic medical center.Methods: The bundled invention was implemented for all abdominal gynecologic surgeries at Prentice Women's Hospital, Chicago, USA, from August 2016 to January 2017, and officially incorporated in department-wide policy from February 1, 2017. SSI data were prospectively collected for any open, vaginal, laparoscopic, or robotic hysterectomy for benign or malignant indications performed from February 2017 to January 2018. A retrospective review of all hysterectomies performed from February 2015 to January 2016 was conducted to establish baseline pre-bundle SSI data.Results: Among 532 hysterectomies performed post-bundle implementation, there were two SSIs. By contrast, there were 14 SSIs among 515 hysterectomies in the same period before bundle implementation, representing a decrease in SSI rate from 2.7% to 0.4% (odds ratio, 7.41; 95% confidence interval, 1.67-32.75). The two SSIs in the post-bundle period occurred in open hysterectomies, whereas 8 (57.1%) SSIs in the pre-bundle period occurred in minimally invasive hysterectomies.Conclusion: An SSI prevention bundle was effective for reducing the SSI rate in hysterectomy for both benign and malignant indications. [ABSTRACT FROM AUTHOR]

Surgery in suspected/confirmed COVID-19 patients is a high-risk venture. In infected patients, COVID-19 is present in the body cavity. During surgery it could be nebulized in the spray generated by surgical instruments and could theoretically infect members of the surgical team. Nevertheless, some surgical gynecologic pathologies cannot be postponed. We present a list of the most frequent gynecologic diseases and recommendations on their surgical management during the COVID-19 pandemic, based on expert opinion, current available information, and international scientific society recommendations to support the work of gynecologists worldwide. In brief, any kind of surgical treatment should be scrutinized and postponed if possible. Nonoperative conservative treatment including pharmacological therapies for hormone-sensitive pathologies should be implemented. Health risk assessment by patient history and COVID-19 test before elective surgery are pivotal to protect both patients and healthcare providers. In confirmed COVID-19 patients or highly suspected cases, elective surgery should be postponed until full recovery. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and efficacy of contained manual morcellation (CMM) with a tissue pouch during minimally invasive robotic or laparoscopic surgeries.Methods: A retrospective cohort study included women who underwent robotic or laparoendoscopic single-site surgery at a tertiary referral center between February 2014 and April 2017. The specimen was postoperatively contained, sliced into one or more long strips, and then pulled out. The surgical type, specimen containment time, containment failure rate, specimen weight, manual morcellation time, and overall CMM speed (g/min) were recorded. Surgical complications related (bowel or bladder injury, ureteral injury, vascular injuries, and tumor dissemination) or not related (delayed wound healing, infection, and hernia) to CMM were also documented. The patients were followed up for 2 years.Results: A total of 165 cases were recorded, comprising 149 cases that underwent laparoscopic and 16 that underwent robotic gynecological surgeries. The average time for specimen containment and manual morcellation in CMM was 6.7 ± 5.0 and 13.2 ± 11.2 min, respectively. The mean morcellation speed was 25.1 ± 8.5 g/min. Among the specimens, those of the uterus with adenomyosis had the lowest CMM speed (21.4 ± 8.0 g/min), whereas those of the uterus with myoma had the highest speed (27.5 ± 8.9 g/min). The pouch perforation rate after CMM was 13.3% and no pouch-related complication was noted.Conclusion: CMM is an efficient method for specimen removal. [ABSTRACT FROM AUTHOR]

Objective: To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity.Methods: Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014.Results: A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27.Conclusion: The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries. [ABSTRACT FROM AUTHOR]

Background: The FIGO Working Group (FWG) in Pelvic Floor Medicine and Reconstructive Surgery (2012-2015) established a consensus among international opinion leaders in evaluating current evidence and providing practice recommendations.Objectives: To provide an update of the previous clinical opinion report on conservative and surgical treatment of posterior compartment prolapse.Search Strategy: Search of evidence was performed using Pubmed, Embase, and Cochrane Library databases up to August 2018.Selection Criteria: Controlled trials on posterior colporrhaphy, site-specific defect, transanal, abdominal, laparoscopic, and mesh repair.Data Collection and Analysis: Collective consensus on surgical outcomes was based on a decision-making process during meetings and multiple group consultations.Main Results: Basic evaluation and conservative treatment precede surgical management. Surgical techniques are performed by vaginal, transperineal, transanal, abdominal, or laparoscopic approach. The transvaginal surgical route without mesh appears superior to the transanal route. No conclusions can be drawn based on clinical studies or randomized controlled trials of posterior colporrhaphy and laparoscopic rectopexy.Conclusions: Management of rectocele should include patients' history, quality of life questionnaires, and, in case of complex anorectal symptoms, imaging and functional studies. Evidence on the best type of posterior vaginal wall repair is still scarce. Randomized controlled trials are needed to determine the best approach to achieve safe, effective, and long-term anatomical and functional outcomes. [ABSTRACT FROM AUTHOR]

Objective: To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad.Methods: In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic.Results: Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006-2008 to 71.4% in 2017-2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%).Conclusion: A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons. [ABSTRACT FROM AUTHOR]

Objective: To observe alterations in surgical planning that were due to the use of ulipristal acetate (UPA) 5 mg daily for symptomatic uterine fibroids.Methods: A prospective cohort trial involving women with symptomatic fibroids was undertaken in 23 clinical practice sites within Belgium between October 1, 2014, and March 31, 2016, to compare initial surgical planning to performed surgical procedures following the use of UPA 5 mg daily for 3 months. Secondary outcomes were surgical complications, reduction in fibroids, bleeding control, and adverse effects.Results: Two hundred and twenty-two women were recruited for the trial. The requirement for surgery decreased with the use of UPA, with 54% of women undergoing surgery after treatment. The reduction in surgery performed was lower for women willing to conceive (40%) compared to women who were not (49%). The volume of the fibroids decreased significantly, with the largest measured fibroid decreasing by 50%. Bleeding and pain were significantly decreased with the use of UPA. No major complications were recorded, and no liver function abnormalities were reported during the treatment and in follow-up.Conclusion: By administering UPA, the required rate of surgery was significantly decreased. Also, the resulting reduction in size of the fibroids could have the potential benefit of reducing surgery-related complications, and long-term use may be warranted to avoid surgery completely. [ABSTRACT FROM AUTHOR]

Objective: To compare the performance of magnetic resonance imaging (MRI) and transvaginal ultrasound (TVU) in detecting deep infiltrating endometriosis (DIE), using Enzian classification. Secondarily, to evaluate the influence of nodule size on the accuracy of MRI and TVU.Methods: A retrospective study was carried out at "La Paz" University Hospital, Madrid, Spain, between April 2012 and December 2014. Inclusion criteria were suspicion of DIE at gynecologic examination, indication to undergo TVU, MRI and surgery. Exclusion criteria were previous hysterectomy, bowel resection, or urinary tract surgery. The diagnosis of DIE using MRI or TVU was considered positive when it correlated with histology. Sensitivity, specificity, accuracy, and mean size of the nodule were calculated.Results: In the present study involving 48 women, TVU demonstrated greater accuracy than MRI for recto-vaginal (77% vs 69%) and vaginal (94% vs 89%) endometriosis. MRI showed greater accuracy (96%) than TVU (92%) for bladder endometriosis. The size of the nodule did not have a significantly different effect on the accuracy of TVU compared with MRI.Conclusion: In the present study, TVU provided a more accurate localization of vaginal and recto-vaginal endometriosis as compared with MRI; however, MRI should be recommended if a suspicion of bladder endometriosis exists. The nodule size did not seem to influence the accuracy of the two techniques. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the values of perineal body (PB) and genital hiatus (GH) before and after posterior repair. We also evaluated the introital surface area (ISA)-a sum of transverse and longitudinal GH measurements.Methods: This secondary analysis of a prospective case series included 94 women undergoing posterior vaginal prolapse surgery at a consultant urogynecology clinic between October 3, 2011, and October 2, 2014. Patients were examined in clinic using the pelvic organ prolapse quantification system with Valsalva maneuver, and in theatre pre- and postoperatively with traction.Results: Immediately postoperatively, a statistically significant change (all P<0.001) was noted for GH (mean difference -0.59 cm), PB (-0.56 cm), and ISA (-0.87 cm) compared with preoperative measurement. This effect was maintained for GH (-0.42 cm) and PB (-0.40 cm) at 2 months' follow-up (both P<0.001), and for PB alone (-0.43 cm; P=0.04) at 8 months. ISA had a moderate correlation with GH (r=0.55).Conclusions: Posterior repair significantly improved PB length at months 2 and 8, and GH length at month 2. ISA did not correlate with prolapse stage. Changes in GH were not maintained beyond postoperative month 2. [ABSTRACT FROM AUTHOR]

Objective: To assess the long-term outcomes of tension-free vaginal tape obturator (inside-out) (TVTO) with or without anterior colporrhaphy.Methods: The present prospective follow-up observational study included patients attending the 2nd Department of Obstetrics and Gynecology, Aretaieio Hospital, University of Athens, Greece, between April 3 and December 20, 2017, for follow-up care after treatment for urodynamic stress urinary incontinence (USUI) with or without cystocele. Patients without cystocele had been treated with TVTO only; those with cystocele underwent TVTO with anterior colporrhaphy. The primary outcome was the objective cure rate assessed by the cough stress test during filling cystometry.Results: Follow-up data were available for 70 patients who underwent TVTO only and 38 who underwent TVTO and anterior colporrhaphy. The mean follow-up period was 13 years. Objective cure was achieved for 57 (81%) patients in the TVTO-only group and 32 (84%) patients in the TVTO and anterior colporrhaphy group. Regarding cystocele management, objective cure was recorded for 35 (92%) patients.Conclusion: At 13-year follow-up, anterior colporrhaphy demonstrated a cure rate of 92% in the management of cystocele, and 84% in the management of cystocele and USUI when combined with TVTO. TVTO alone for the management of USUI had an objective cure rate of 81%. [ABSTRACT FROM AUTHOR]

Enhanced recovery protocols consist of a bundle of concepts including early feeding, opioid-sparing multimodal pain management, and euvolemia, with the overarching goal of hastening postoperative recovery. Enhanced recovery after surgery has been shown to reduce hospital length of stay, reduce costs, and decrease perioperative opioid requirements in benign and oncologic gynecologic surgery. Interventions without supporting evidence of benefit, such as the use of mechanical bowel preparation, routine use of nasogastric tubes and surgical drains, caloric restriction, routine use of intravenous opioid analgesics, and over-vigorous intravenous hydration should be discouraged to improve broader endpoints such as patient satisfaction and overall recovery. Successful implementation requires engagement from a multidisciplinary team including surgeons, anesthesiologists, nurses, and pharmacists. [ABSTRACT FROM AUTHOR]

Objective: To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure.Methods: The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6 months.Results: In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30 cm H2 O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI.Conclusion: Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure. [ABSTRACT FROM AUTHOR]