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Objective. The aim of this study was to assess postoperative incisional pain and cosmetic scores in mini-laparoscopic gynecological surgeries undertaken with different port sizes. Material and Method. In this prospective study, all women who underwent mini-laparoscopic gynecological surgery with 2.4-, 3-, and 5-mm lateral ports for benign gynecological conditions between March 2017 and April 2019 were included. The primary outcome was postoperative incisional pain at rest, walking, and after a provoked Valsalva maneuver assessed by numeric rating scale scores at 6 hours, 12 hours, 24 hours, and 3 days and 7 days after surgery. Secondary outcome measures included cosmetic scores of each port site (evaluated by using patient-observer scar assessment scale [POSAS]), operation time, and intra- and postoperative complications. Results. A total of 330 lateral port sites in 110 patients who underwent benign gynecological surgery via mini-laparoscopy were assessed for pain and cosmetic appearance. Pain scores at each time point were significantly lower for 2.4- and 3-mm ports than those for 5-mm ports; however, no significant difference was detected between 2.4-mm and 3-mm port sites (P =.6). The difference was more evident at 24 hours when routine analgesic drugs were stopped (P =.004). For POSAS scores, both 2.4-mm and 3-mm ports were superior to 5-mm port sites (P =.002); however, there was no significant difference between 2.4-mm and 3-mm port sites (P =.2). There were 2 port-related complications: one subcutaneous emphysema and one bleeding from a 5-mm trocar site 1 hour after surgery. Conclusion. Mini-laparoscopic gynecologic surgery using smaller ports resulted in decreased postoperative incisional pain and superior cosmetic appearance. [ABSTRACT FROM AUTHOR]

Add-on treatments in IVF are utilized to a great extent but without sufficient evidence showing their effectiveness. Since the offered treatments are usually costly and may be associated with yet unknown risks, this practice is not in the best interest of couples that may go to great lengths to conceive and have an offspring carrying their own genetic make-up. A recent addition to this armamentarium is the administration of platelet-rich plasma (PRP) in women with diminished ovarian reserve, implantation failures, and a thin endometrium. The only evidence for PRP comes from small scale and mostly before and after studies with clinically irrelevant end points. PRP has not been subjected to a rigorous clinical trial. It is a typical example of an add-on gaining widespread popularity based on biological plausibility and mind-bending theoretical presumptions. We should be extremely cautious prior to implementing PRP on a widescale and await the results of well-designed studies. [ABSTRACT FROM AUTHOR]

Objective: To compare the operation time and performance of two uterine manipulators used for total laparoscopic hysterectomy (TLH). Material and methods: Design: Retrospective cohort analysis. Design classification: Canadian Task Force Classification II-2. Setting: Tertiary-care university-based teaching hospital and academic affiliated private hospital. Patients: All consecutive patients who underwent for TLH between January 2014 and June 2017. All operations were performed by two expert endoscopic surgeons using one of the following uterine manipulators depending on surgeon preferences: Clermont-Ferrand (CF) or Vectec (VT) MAUT60. Patients were excluded if additional surgeries such as urogynecological procedures were performed, TLH was converted to laparotomy prior to colpotomy, and when their operation records could not be obtained. A total of 169 patients were added to final analysis. Operation time, colpotomy time and the subjective performance of manipulators such as movement of the uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were evaluated by watching un-edited operation videos. Results: A total of 169 patients (83 patients in CF group; 86 patients in VT group) were included in the final analysis. Patients' baseline characteristics were comparable between groups. Operation time and time required for colpotomy were significantly shorter in the VT group. Lateral movements of the manipulators and elevation of the uterus were better with VT compared to CF (p = .001 for both). Compared to the CF, VT was superior for visualization of the vaginal fornices (p = .004) and maintenance of pneumoperitoneum (p < .001). Both surgeons had perfect agreement on the performance grading of manipulators (p < .001, Kappa values were between 0.86-0.92). There was no difference between groups in estimated blood loss and duration of hospital stay. Reinsertion or the need to change the manipulator was not required in either group. No pelvic or vaginal abscess, cuff cellulitis, dehiscence, or hematoma formations were noted. Conclusion: Laparoscopic hysterectomy assisted with the VT uterine manipulator is associated with shorter operation and colpotomy time. Furthermore, the movements of uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were significantly better with VT compared to the CF manipulator. [ABSTRACT FROM AUTHOR]

Objective: To evaluate clinical and operative outcomes of transvaginal extraction (TVE) and contained power morcellation (CPM) for myoma retrieval after laparoscopic myomectomy.Materials and Methods: Prospective data from 35 consecutive cases using CPM were compared with retrospective data of all cases using TVE from December 2014 to January 2017. Patients were matched 1:1 based on myoma diameter. A total of 62 women were included in the final analysis. Specimen retrieval was performed using the TVE or CPM within an insufflated isolation bag.Results: Age, body mass index, mode of prior obstetric delivery, history of previous abdominal surgery, indication for myomectomy, and the myoma(s) characteristics were similar between groups. Retrieval time was significantly shorter in the TVE group compared with the CPM group: 10 minutes (3-15 minutes) versus 17 minutes (14-42 minutes); P < .001. Time required for placement of the instruments was 9.7 minutes for the isolation bag and 0.5 minutes for the vaginal extractor. Additional analgesic administration for pain relief was necessary in 13 patients (42%) in the TVE group and 23 patients (72%) in the CPM group ( P = .01). Total cost of the hospital stay was significantly higher in the CPM group compared with the TVE group ( P < .001). Estimated blood loss and duration of hospital stay were similar between groups.Conclusion: Both CPM and TVE can be used for safe retrieval of large myomas that are removed laparoscopically. Compared with CPM, TVE was associated with a shorter retrieval time, less postoperative pain, and less hospital costs. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To evaluate the safety and efficacy of unidirectional barbed suture technique for vaginal cuff closure in total laparoscopic hysterectomy (TLH). Methods: In a retrospective chart review, data were analyzed from 165 patients who underwent a TLH with an unidirectional barbed suture technique for vaginal cuff closure from January 2012 to June 2016 at tertiary‐care university‐based teaching hospital and academic affiliated hospital. Vaginal cuff was closed by single layer 3/0 V‐Loc unidirectional 9″, 180 day Absorbable Wound Closure Device (Covidien Healthcare, Mansfield, MA) and the suture was not stitched backward to secure distal end. Results: A total of 165 patients were included and the median age was 50 years (range, 35–84 years). The median completion time for hysterectomy time was 100 min (range, 40–240 min) and the median vaginal cuff closure time was 7 min (range, 4–15 min). The median estimated blood loss was 87.8 mL (range 30–250 mL) and the median uterine weight was 200 g (range, 40–900 g). Intraoperative complication included bladder perforation (1.2%) and postoperative complications were vaginal cuff dehiscence (1.8%), cuff cellulitis (0.6%), vesicovaginal fistula (0.6%) and unexplained fever (0.6%). Conclusion: According to the results of current study, the use of unidirectional barbed suture without backward stitching appears to be safe for the vaginal cuff closure in TLH. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the feasibility of intraoperative endoscopic ultrasound guidance for excision of symptomatic deep intramural myomas that are not otherwise visible at laparoscopy. Seventeen patients with symptomatic deep intramural myomas who underwent laparoscopic myomectomy with intraoperative endoscopic ultrasound guidance were followed up and reported. All myomas were removed successfully. The endometrium was breached in one patient. All patients were relieved of their symptoms and three patients presenting with infertility conceived. There were no short- or long-term complications associated with the procedure. One patient who had multiple myomas necessitated intravenous iron treatment prior to discharge. Laparoscopic removal of small symptomatic deep intramural myomas is facilitated by the use of intraoperative endoscopic ultrasound that enables exact localisation and correct placement of the serosal incision. IMPACT STATEMENT • What is already known on this subject: When the myoma is symptomatic, compressing the endometrium, does not show serosal protrusion and is not amenable to hysteroscopic resection, laparoscopic surgery may become challenging. • What do the results of this study add: The use of intraoperative endoscopic ultrasound under these circumstances may facilitate the procedure by accurate identification of the myoma and correct placement of the serosal incision. • What are the implications of these findings for clinical practice and/or further research: Intraoperative ultrasound should be more oftenly used to accurately locate deep intramural myomas to the end of making laparoscopy feasible and possibly decreasing recurrence by facilitating removal of otherwise unidentifiable disease. [ABSTRACT FROM AUTHOR]

Objective: The aim of this research was to evaluate the efficacy and safety of the PlasmaKinetic™ (PK) PKS OMNI® (Gyrus ACMI, Maple Grove, MN) sealing device in laparoscopic hysterectomy. Materials and Methods: For this retrospective observational study, 60 patients who underwent multiport total laparoscopic hysterectomy between January 2014 and January 2015 in a tertiary-care university-based teaching hospital and an academically affiliated hospital were included in this study. The PKS OMNI is a bipolar electrosurgical device that takes energy from a PK generator workstation G400. This pulsed wave system has two different modes; cutting (High Cut 1,2,3) and coagulation (Vaporization 1,2,3). Results: Records of 60 patients were analyzed. The median age was 50 (range: ages 40-84), median body mass index was 26 kg/m2 (range: 22-32 kg/m2), and median parity was 2 (range: 1-8). The median total operation time was 100 minutes (range: 70-240 minutes), estimated blood loss was 80 mL (range: 30-250 mL), and uterine weight was 207 g (range: 50-900 g). Degree of Surgical Difficulty and postoperative pain scores at rest were evaluated with a visual analogue scale system, from 0 to 10, and the medians of these scores were 5 (range: 3-7) and 4 (range: 2-6), respectively. The median recovery time of bowel movement was 16 hours (range: 8-26 hours), median spontaneous urination time was 7 hours (range: 4-29 hours), and median postoperative mobilization time was 8 hours (range: 6-10 hours). Conversion to laparotomy was needed in 1 patient due to severe pelvic adhesions. The median duration of hospital stay was 2 days (range: 2-4 days). Vaginal cuff dehiscence was detected in 1 (1.7%) patient who engaged in sexual intercourse on the 122nd day after surgery. Cuff cellulitis in 1 (1.7%) patient and unexplained fever in 1 (1.7%) patient were the other recorded complications. The median follow-up time was 12 months (range: 6-17 months). Conclusions: The PKS OMNI is a novel, underused energy modality that promotes quick recovery and acceptable operation time with minimal blood loss. (J GYNECOL SURG 33:253) [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the feasibility of intraoperative endoscopic ultrasound guidance for excision of symptomatic deep intramural myomas that are not otherwise visible at laparoscopy. Seventeen patients with symptomatic deep intramural myomas who underwent laparoscopic myomectomy with intraoperative endoscopic ultrasound guidance were followed up and reported. All myomas were removed successfully. The endometrium was breached in one patient. All patients were relieved of their symptoms and three patients presenting with infertility conceived. There were no short- or long-term complications associated with the procedure. One patient who had multiple myomas necessitated intravenous iron treatment prior to discharge. Laparoscopic removal of small symptomatic deep intramural myomas is facilitated by the use of intraoperative endoscopic ultrasound that enables exact localisation and correct placement of the serosal incision. Impact statement What is already known on this subject: When the myoma is symptomatic, compressing the endometrium, does not show serosal protrusion and is not amenable to hysteroscopic resection, laparoscopic surgery may become challenging. What do the results of this study add: The use of intraoperative endoscopic ultrasound under these circumstances may facilitate the procedure by accurate identification of the myoma and correct placement of the serosal incision. What are the implications of these findings for clinical practice and/or further research: Intraoperative ultrasound should be more oftenly used to accurately locate deep intramural myomas to the end of making laparoscopy feasible and possibly decreasing recurrence by facilitating removal of otherwise unidentifiable disease. [ABSTRACT FROM AUTHOR]

Cesarean scar pregnancy (CSP) is a rare, but life-threatening type of ectopic pregnancy. An exact and early diagnosis of CSP is very important for prognosis. The aim of the present study was to describe 4 women with CSP and discuss their clinical presentations, diagnoses, and various management options along with the published literature. Four women with a suspicion of CSP or cervical pregnancy were referred to our hospital between August 2013 and January 2014. All the patients were counseled about medical management options. After the treatment, serum beta human chorionic gonadotropin (β-hCG) levels were followed weekly until they reached <5 mIU/mL. All the patients were diagnosed at the first trimester, with the average gestational age of 6.4±0.9 weeks. Treatment was systemic methotrexate (MTX) treatment in 3 of the 4 women, requiring no further intervention. The remaining 1 woman was treated with an intragestational administration of MTX. The mean time passed until β-hCG reached <5 mIU/mL was 10.2±2.9 (range, 8-14) weeks, and the mean time passed until the gestational sac resolved was 21.5±3.5 (range, 18-25) weeks. Based on this limited number of case-series experience, it seems that CSP should be treated conservatively even if there are visible fetal cardiac activity, fetal poles, large gestational sacs, and high initial β-hCG levels. Although the complete remission of the lesion takes a relatively long time, medical management via a noninvasive approach and follow-up should be tried as the first choice of therapy. [ABSTRACT FROM AUTHOR]

Background: Microdose flare-up GnRH agonist and GnRH antagonist have become more popular in the management of poor ovarian responders (POR) in recent years; however, the optimal protocol for POR patients undergoing in vitro fertilization has still been a challenge. Methods: In this observational study design, two hundred forty four poor ovarian responders were retrospectively evaluated for their response to GnRH agonist protocol (group-1, n=135) or GnRH antagonist protocol (group-2, n=109). Clinical pregnancy rate was the primary end point and was compared between the groups. Student t-test, Mann Whitney U test and  2 -test were used to compare the groups. The p<0.05 was considered to show a statistically significant result. Results: The mean total gonadotropin doses were 3814±891 IU in group 1 and 3539±877 IU in group 2 (p=0.02). The number of metaphase-II oocytes (3.6±2.4 vs. 2.8±1.9, p=0.005) and implantation rates (27.8% vs. 18.8%, p=0.04) in group 1 and group 2, respectively were significantly different. The fertilization rate in group 1 and group 2 was 73% vs. 68%, respectively (p=0.5) and clinical pregnancy rate was 19.8% vs. 14.4%, respectively (p=0.13). Conclusion: The GnRH agonist microdose flare-up protocol has favorable outcomes with respect to the number of oocytes retrieved and implantation rate; nevertheless, the clinical pregnancy rate was found to be similar in comparison to GnRH antagonist protocol in poor ovarian responders. GnRH antagonist protocol appears to be promising with significantly lower gonadotropin requirement and lower treatment cost in poor ovarian responders. [ABSTRACT FROM AUTHOR]

Background: Endometriosis is a complex disease with a spectrum of pain symptoms from mild dysmenorrhea to debilitating pelvic pain. There is no concrete evidence in the literature whether endometriotic cyst per se, causes pain spectrum related to the disease. The aim of the present study was to evaluate the effect of surgical removal of endometriomas on pain symptoms. Materials and Methods: In this prospective, observational, before-after study, which was conducted between March 2012 and January 2013 in Training and Research Hospital, Adana, Turkey, a total of 23 patients including 16 sexually active and 7 virgin symptomatic women were questioned for non-cyclic pelvic pain (NCPP), intensity of the NCPP, presence of cyclic dysmenorrhea, and dyspareunia before and after the endometrioma operation. Participants who were sonographically diagnosed and later pathologically confirmed as having endometrioma without sign and symptoms of deep infiltrative endometriosis (DIE) were also questioned for pain symptoms before and after the laparoscopic removal of cyst wall. Patients with intraabdominal adhesions, history of pelvic inflammatory disease, and pathological diagnosis other than endometrioma were excluded. No ancillary procedures were applied for pain management, but if pain was present, pelvic peritoneal endometriotic lesions were ablated beside the removal of ovarian endometriotic cysts. Results: Out of 23 cases with endometrioma, 91 and 78% reported to have NCPP and dysmenorrhea, respectively, before the operation, while 60 and 48%, respectively, after the operation (McNemar's test, P=0.016 for both figures). Among the sexually active cases, 31% (5/16) had dyspareunia before the operation and only 1 case reported the pain relief after the operation (McNemar's test, P=1). Intensity of NCPP were reported to be none (8.7%), moderate (21.7%), severe (56.5%) and unbearable (13%) before the operation and decreased to none (43.5%), mild (43.5%), moderate (4.3%) and severe (8.7%) after the operation (Wilcoxon signed-rank test, P<0.001). Conclusion: In symptomatic cases with ovarian endometrioma, without sign and symptoms of DIE, laparoscopic removal of the cysts with/without ablation of the peritoneal endometriotic lesions yields relief of NCPP and cyclic dysmenorrhea, but not dyspareunia. [ABSTRACT FROM AUTHOR]

Objective To compare the adhesion and histologic scoring of barbed and standard suture material after incision and serosal closure of both uterine horns for myomectomy model in rats. Study design In this single blind randomized controlled trial, one cm incisions were performed on the right and left uterine horns of ten non-pregnant rats, and these incisions were randomly allocated for closure by a suture material with either polyglyconate (V-Loc™) or polyglactin-910 (Vicryl ® ). Each rat served as its own control. Six weeks after the operation, the abdomen was re-opened and the abdominal and surgical sites were evaluated by a researcher blinded to the side of the suture materials in the first operation. Adhesions were scored according to their severity, and specimens were also evaluated and scored histologically according to the following features: collagen deposition and inflammatory reaction. Results The median macroscopic adhesion scores in the barbed and standard suture group were 3.5 and 2, respectively ( p = .008). There was significant difference between the barbed and standard suture group with regard to the median inflammatory cell scores for macrophages-foreign body giant cell (1 vs. 3, respectively, p = .01) and mononuclear cell (2 vs. 3, respectively, p = .04). Conclusion Based on the results of the present study, we suggest that in the rat model, the type of the suture used for myometrial closure has an effect on subsequent adhesion formation, and this adverse outcome was more frequently observed with the barbed suture. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to investigate whether the use of low molecular weight heparin (LMWH) improve live birth rates when compared with control group in patients with unexplained recurrent miscarriages (URM). Methods: In this prospective observational study 150 women with a history of two or more previous unexplained first trimester pregnancy loss who received LMWH; either enoxaparin (n=50), tinzaparin (n=50) or nothing (n=50) were followed for the pregnancy outcome measures. Only the patients who have used standardized dosage of LMWH (4000 IU/day enoxaparin or 3500 IU/day tinzaparin) were included to the study. The primary end point was the live birth rate and secondary end points were the side effects, late pregnancy complications and neonatal outcome in the study cohorts. Results: Live birth was achieved 85% of the LMWH group and 66% of the control group (p=0.007). According to the subgroup analysis; live birth rates did not differ significantly between the enoxaparin and tinzaparin group (84% and 86%, respectively). Maternal and neonatal side effects were not statistically significant among the study participants. Conclusion: Thromboprophylaxis with LMWH resulted in a improved live-birth rate in patient with 2 or more consecutive unexplained recurrent pregnancy loss. Nevertheless these findings need to be confirmed in larger randomized trials. [ABSTRACT FROM AUTHOR]

Objective: To study the effect of body composition on reproduction in women with unexplained infertility treated with a controlled ovarian hyperstimulation and intrauterine insemination programme. Methods: This prospective observational study was conducted on 308 unexplained infertile women who were scheduled for a controlled ovarian hyperstimulation and intrauterine insemination programme and were grouped as pregnant and non-pregnant. Anthropometric measurements were performed using TANITA-420MA before the treatment cycle. Body composition was determined using a bioelectrical impedance analysis system. Results: Body fat mass was significantly lower in pregnant women than in non-pregnant women (15.61±3.65 vs.18.78±5.97, respectively) (p=0.01). In a multiple regression analysis, body fat mass proved to have a stronger association with fecundity than the percentage of body fat, body mass index, or the waist/hip ratio (standardized regression coefficient=0.277, t-value=2.537; p<0.05). The cut-off value of fat mass, which was evaluated using the receiver operating characteristics curve, was 16.65 with a sensitivity of 61.8% and a specificity of 70.2%. Below this cut-off value, the odds of the pregnancy occurrence was found to be 2.5 times more likely. Conclusion: Body fat mass can be predictive for pregnancy in patients with unexplained infertility scheduled for a controlled ovarian hyperstimulation and intrauterine insemination programme. [ABSTRACT FROM AUTHOR]

Background: Lymphoma of primary genital tract is uncommon. The similarity of its symptoms (vaginal bleeding, pelvic pain, etc..) with other genital system diseases, presence of nonspesific symptoms on histologic and imaging examinations may make the diagnosis delayed and may cause overtreatment. Case report: A-62 years old woman presented with postmenoposal bleeding. All the imaging studies [transvaginal ultrasonography (USG), Doppler USG, magnetic resonance imaging (MRI)] showed only enlarged uterus with a mass lesion orginated from uterine wall. The histopathologic analysis of fractionated cervical and uterine curettage were not diagnostic for postmenoposal bleeding and uterine mass lesion. To clarify the diagnosis, total abdominal hysterectomy (TAH), bilateral salpingooferectomy (BSO), peritoneal cytology sampling and frozen were carried out. While the frozen was reported in favour of malign pathology, the operation was continued with bilateral pelvic and paraaortic lymph node dissection (BPPLND) and omentectomy. Routine pathology demonstrated diffuse large B cell lymphoma infiltrating myometrial wall. Bone marrow examination was normal. Flourodeoxyglucose positron emission tomography / computered tomography (FDG-PET/CT) showed no FDG-avid area in favour of lymphoma on whole body scan. She was considered as primary uterine lymphoma and received rituximab, cyclophosphamide, adriamycin, vincristine ve prednisolone (R-CHOP) chemotherapy by hematology clinical follow up. She remains in complete clinical and radiological remission 6 months after the treatment. Conclusion: Lymphoma of genital tract should be kept in mind in the case of difficulty to clarify the differential diagnosis of uterine bleeding or mass. Especially if uterine lymphoma infiltrated to the uterine wall deeply, preoperative histological analysis could not reveal the real pathology. [ABSTRACT FROM AUTHOR]

Objective: To study the use of the Bologna criteria (BC) for the definition of poor ovarian responders (POR) in clinical practice and research.Design: Systematic review of published and unpublished/ongoing trials between January 2012 and August 2017 on POR.Setting: Not applicable.Patient(s): Not applicable.Intervention(s): The databases were searched using the relevant medical subject headings including all subheadings. The search was limited to humans and English language. The references of the included studies were cross-searched for possibly missed articles. Only clinical trials providing an evidence level ≥ III were included. Case reports, review, letters, and hypothetical articles were excluded.Main Outcome Measure(s): Extracted studies were divided into two groups: studies in which the BC were used or not.Result(s): One hundred nine published clinical studies analyzing a total of 30,540 women and 112 unpublished/ongoing trials were identified. The BC were used to define POR in 56 (51%) of the published and 44 (39%) of the unpublished trials. The use of the BC gradually increased from 29% to 53% from 2012 to 2017. Asian researchers were more likely to use the BC compared with European and North American researchers (65%, 49%, and 23%, respectively). Neither the design of the study nor the impact factor of the publishing journal was correlated with the use of the BC.Conclusion(s): There is still reluctance to use the BC for the definition of POR, which makes it difficult to combine data from small studies and reach a meaningful conclusion. [ABSTRACT FROM AUTHOR]

Spondylodiscitis is a rare but severe complication of sacral colpopexy (SC) procedure. Although the term 'spondylodiscitis' refers to infection of vertebral body and intervertebral disc space, neither the infecting microorganism could be isolated nor any purulent material could be observed during the second surgery and there was failure of different regimens of antibiotherapy. This type of spondylodiscitis cases might be explained by the graft rejection hypothesis. We hypothesize that the initiator of the rejection process is the host response solely and infection is just a co-incidence. In this situation, infection is neither a cause of this reaction, nor a promoter. There might be no infection at all. We presented two spondylodiscitis cases most probably secondary to graft rejection reaction and reviewed the literature in order to increase the awareness of this destructive complication of SC, which can only be ameliorated by surgical mesh removal. [ABSTRACT FROM AUTHOR]