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Importance: The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide. Objective: The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery. Evidence acquisition: We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included. Results: We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0–67%, and 85%, respectively. Conclusions and relevance: Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility. [ABSTRACT FROM AUTHOR]

Ovarian cancer is one of the most common causes of cancer death in women worldwide. Most often, it is detected in an advanced stage due to its insidious onset and lack of symptoms in stages I and II. That is why imaging diagnostics is so important. Therefore, we assessed the consistency of the image seen on CT with the actual image assessed during surgery. Objectives: The aim of this study is to compare preoperative evaluation based on CT reports with those obtained during ovarian cancer surgery to determine whether CT is helpful in assessing the possibility of optimal or complete cytoreduction. Methods: This retrospective study included patients diagnosed with ovarian cancer who underwent diagnostic laparoscopy or laparotomy with cytoreduction. We compared ovarian cancer lesions described by radiologists on CT scans to those described during laparoscopy or laparotomy; the Wilcoxon signed-rank test for paired observations was used to compare the variables. Results: We observed that the morphology of the tumor, mesenteric infiltration, and the assessment of the involvement of the abdominal, para-aortic, and iliac lymph nodes may differ in CT examination and during surgery. Conclusions: The site of the tumor exit on a CT scan does not always reflect the original site seen during surgery. [ABSTRACT FROM AUTHOR]

The aim of this quality improvement (QI) project was to assess postoperative narcotic use after pediatric gynecologic surgeries and establish standard postoperative opioid dosing. Through standard dosing, we hoped to decrease variability in postoperative opioid prescriptions and decrease excess opioid doses in the community. This quality improvement project was approved by the Children's Minnesota institutional review board. Counseling on postoperative pain management was provided pre- and postoperatively. At the 2-week postoperative visit, patients were asked about the number of opioid doses used and pain control satisfaction. Baseline data were collected for 6 months, with surgeons prescribing the number of opioid doses on the basis of their personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established, and data collection was repeated. Complete data were recorded for 30 cases before implementation of standard doses and for 29 cases after implementation. Standardized opioid dosing resulted in a 30% decrease in total opioid doses in circulation (252 to 176 doses; P =.014) and a 15% reduction in excess doses in circulation (162 to 137 doses). Forty-three percent of patients did not use any opioid doses. There was no significant difference (P =.8818) in patient pain control satisfaction rating. Standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient pain control satisfaction. Opioid dose standardization may decrease opioid circulation within the community. Approximately 2 of every 5 patients used 0 opioid doses, which suggests that a further reduction in the standard dose prescriptions is possible. [ABSTRACT FROM AUTHOR]

To identify knowledge gaps in business education among obstetrics and gynecology fellows An online anonymous survey was distributed to obstetrics and gynecology subspecialty fellows, including pediatric and adolescent gynecology, minimally invasive gynecologic surgery, and reproductive endocrinology and infertility fellows. Of the 483 fellows who received the questionnaire, 159 completed the surveys, resulting in a response rate of 32.9%. A total of 80 reproductive endocrinology and infertility fellows (50.3%), 47 minimally invasive gynecologic surgery fellows (29.6%), and 32 pediatric and adolescent gynecology (20.1%) fellows completed the survey. Over half reported debt from either undergraduate or medical school (52.2%). Over half (58.5%) reported 0 hours of finance education in their residency or fellowship training. In general, fellows reported relatively higher levels of confidence in nonmedical aspects of business, such as purchasing a home (63.9%), life and disability insurance (57.2%), and making financial plans for the future (57.9%). Conversely, a large portion of fellows reported feeling "not at all confident" in business topics related to the field of medicine, including contract negotiation (24.7%), non-competes (27.1%), relative value units system–based pay (32.0%), general office practice management (58.2%), legal aspects of business (71.8%), accounting and billing (54.4%), and marketing (55.7%). Our survey demonstrates an unmet demand among obstetrics and gynecology fellows to learn topics related to the business of medicine. Knowledge of these topics is critical for those pursuing private practice or academic medicine. Future initiatives should evaluate other subspecialties and prioritize creating a standardized education tool to better prepare trainees entering medical practice. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to compare fast-track surgery (FTS) and traditional perioperative care protocols in laparoscopic gynecological surgeries, assessing their impact on length of stay (LOS), recovery time, and postoperative complications. Methods: A case-control retrospective study was conducted at Suzhou Hospital of Integrated Chinese and Western Medicine, involving 167 patients undergoing laparoscopic gynecological surgery from June 2021 to June 2023. Of them, 81 patients underwent surgery based on the FTS protocol (FTS group) and 86 patients received a traditional perioperative management (control group). Patients in both groups underwent gynecologic laparoscopic procedures, including uterine, ovarian and tubal surgeries. Data were collected on general patients’ characteristics, including age, BMI, surgery type and time, intestinal recovery and out-of-bed activity time, LOS, pain levels, and postoperative complications. Wilcoxon rank sum test with continuity correction was used to assess the difference in operative characteristics and postoperative pain levels. Fisher’s exact test was used to assess the difference in overall frequency of postoperative complications between groups. Results: Patients in the FTS group exhibited faster intestinal recovery, shorter mobilization time, and reduced LOS compared to the control group. Pain levels were significantly lower at one, six and twelve hours post-surgery in the FTS group. Overall, the proportion of postoperative complications was significantly lower in the FTS group than in the control group. Conclusions: Implementing the FTS protocol in laparoscopic gynecological surgeries for benign conditions can reduce LOS, accelerate recovery, and minimize pain without increasing postoperative complications. Further research with more diverse patient populations is warranted to validate these findings. [ABSTRACT FROM AUTHOR]

Bleeding after laparoscopic gynaecological surgery remains a potential complication. We assessed RADA16 (PuraStat®), a topical self‐assembling peptide haemostatic agent, in a pilot study of 46 women undergoing laparoscopic gynaecological surgery. The primary outcome was intraoperative haemostatic efficacy for resection site bleeding. Haemostasis was achieved in all intraoperative bleeding situations (40/40 participants: 100%) with no clinically significant surgical bed bleeding or complications. Mean volume and time required to achieve haemostasis were 6 mL and 14 sec, respectively. This study suggests that PuraStat® is a safe, effective haemostatic agent in laparoscopic gynaecological surgery. Randomised controlled trials are warranted to confirm these findings. [ABSTRACT FROM AUTHOR]

The article deals with the social insurance status of a self-employed surgeon who shares an operating room in a hospital. The Bavarian State Social Court has ruled that the doctor is considered self-employed and therefore not subject to social insurance obligations. It describes the collaboration between a group practice for operative gynecology and a clinic, where the doctors from the group practice work together with the clinic's operating team. The Social Court has decided that the doctor's activity is not subject to insurance obligations. It emphasizes that the doctor's activity is considered independent. Furthermore, it reports on compensation payments in the healthcare sector, where the Administrative Court dismissed a clinic's lawsuit. [Extracted from the article]

Aim: To identify factors influencing the Trendelenburg angle required during laparoscopic gynecological surgery. Methods: Patients who underwent laparoscopic surgery at a single university hospital between May 1, 2019, and March 31, 2021 were enrolled. Data were extracted from the medical records, while magnetic resonance imaging scans and all laparoscopic surgery videos were retrospectively reviewed to assess the presence of the small intestine in the pelvic cavity as well as the adhesions at each site. Groups with and without the small intestine in the pelvic cavity, and those requiring a Trendelenburg angle above or below 13° were compared. Results: In total, 219 patients were examined. The Trendelenburg angle was significantly higher (p = 0.004), while a significant increase in ovarian adhesions was observed (p = 0.033; odds ratio [OR], 2.30; 95% confidence interval [CI], 1.05–5.01) in the group without the presence of the small intestine in the pelvic cavity. Furthermore, the group requiring a Trendelenburg angle of ≥13° had significantly thicker subcutaneous fat (p = 0.044) and more ileal adhesions (p = 0.040, OR, 1.82; 95% CI, 1.03–3.23) than the group with an angle of <13°. Conclusion: Cases of ileal adhesions or thick subcutaneous fat are more likely to require a Trendelenburg angle of ≥13°. Therefore, Trendelenburg complications should be considered in this group. In addition, ovarian adhesions make it more difficult to exclude the small intestine from the small pelvic cavity, and may be associated with endometriosis. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Lateral suspension is an abdominal prosthetic surgical procedure used to correct apical prolapse. The procedure involves the placement of a T-shaped mesh on the anterior vaginal wall and on the isthmus or uterine cervix that is suspended laterally and posteriorly to the abdominal wall. Since its description in the late 90s, modifications of the technique have been described. So far, no consensus on the correct indications, safety, advantages, and disadvantages of this emerging procedure has been reached. Methods: A modified Delphi process was used to build consensus within a group of 21 international surgeons who are experts in the performance of laparoscopic lateral suspension (LLS). The process was held with a first online round, where the experts expressed their level of agreement on 64 statements on indications, technical features, and other aspects of LLS. A subsequent re-discussion of statements where a threshold of agreement was not reached was held in presence. Results: The Delphi process allowed the identification of several aspects of LLS that represented areas of agreement by the experts. The experts agreed that LLS is a safe and effective technique to correct apical and anterior prolapse. The experts highlighted several key technical aspects of the procedure, including clinical indications and surgical steps. Conclusions: This Delphi consensus provides valuable guidance and criteria for the use of LLS in the treatment of pelvic organ prolapse, based on expert opinion by large volume surgeons' experts in the performance of this innovative procedure. [ABSTRACT FROM AUTHOR]

Introduction: High body mass index (BMI) is a risk‐factor for stress urinary incontinence (SUI). Mid‐urethral sling (MUS) surgery is an effective treatment of SUI. The aim of this study was to investigate if there is an association between BMI at time of MUS‐surgery and the long‐term outcome at 10 years. Material and Methods: Women who went through MUS surgery in Sweden between 2006 and 2010 and had been registered in the Swedish National Quality Register of Gynecological Surgery were invited to participate in the 10‐year follow‐up. A questionnaire was sent out asking if they were currently suffering from SUI or not and their rated satisfaction, as well as current BMI. SUI at 10 years was correlated to BMI at the time of surgery. SUI at 1 year was assessed by the postoperative questionnaire sent out by the registry. The primary aim of the study was to investigate if there is an association between BMI at surgery and the long‐term outcome, subjective SUI at 10 years after MUS surgery. Our secondary aims were to assess whether BMI at surgery is associated with subjective SUI at 1‐year follow‐up and satisfaction at 10‐year follow‐up. Results: The subjective cure rate after 10 years was reported by 2108 out of 2157 women. Higher BMI at the time of surgery turned out to be a risk factor for SUI at long‐term follow‐up. Women with BMI <25 reported subjective SUI in 30%, those with BMI 25—<30 in 40%, those with BMI 30—<35 in 47% and those with BMI ≥35 in 59% (p < 0.001). Furthermore, subjective SUI at 1 year was reported higher by women with BMI ≥30, than among women with BMI <30 (33% vs. 20%, p < 0.001). Satisfaction at 10‐year follow‐up was 82% among women with BMI <30 vs 63% if BMI ≥30 (p < 0.001). Conclusions: We found that higher BMI at the time of MUS surgery is a risk factor for short‐ and long‐term failure compared to normal BMI. [ABSTRACT FROM AUTHOR]

Introduction: The objective of the study was to provide a comprehensive description of perioperative morbidity associated with robot‐assisted surgery (RAS) in a gynecological oncology setting in order to improve the preoperative counseling of women and support shared decision‐making. Material and Methods: All women scheduled for intended RAS between January 2015 and December 2022 were prospectively included in an electronic morbidity database for the analyses of perioperative complications. Results: In total, 2225 women were included. Sixty‐four patients (2.9%) experienced an intraoperative complication. Intraoperative complications were associated with a higher rate of conversion to laparotomy (15.6% vs. 1.8%, p < 0.001), a higher rate of major postoperative morbidity (9.3% vs. 2.4%, p < 0.001), and a higher rate of reoperation (9.3% vs. 1.7%, p < 0.001), compared to cases without intraoperative complications. Thirty‐day postoperative morbidity was evaluated according to the Memorial Sloan‐Kettering Cancer Center Surgical Secondary Events Grading System. Grade 3–5 events were considered major. A total of 57 patients (2.6%) experienced a major event after surgery, postoperative rupture of the vaginal vault being the most common complication requiring surgical intervention. Conversion to laparotomy occurred in 49 cases (2.2%) and was associated with higher intraoperative blood loss (300 mL vs. 25 mL, p < 0.001), a higher rate of postoperative major events (20.4% vs. 2.2%, p < 0.001), and a higher rate of reoperation (11.8% vs. 1.6%, p < 0.001). Conclusions: Our study demonstrates low rates of major perioperative morbidity and conversion to laparotomy after RAS performed by trained high‐volume surgeons in a gynecological oncology setting. [ABSTRACT FROM AUTHOR]

Introduction: There is a growing emphasis on proficiency‐based progression within surgical training. To enable this, clearly defined metrics for those newly acquired surgical skills are needed. These can be formulated in objective assessment tools. The aim of the present study was to systematically review the literature reporting on available tools for objective assessment of minimally invasive gynecological surgery (simulated) performance and evaluate their reliability and validity. Material and methods: A systematic search (1989–2022) was conducted in MEDLINE, Embase, PubMed, Web of Science in accordance with PRISMA. The trial was registered with the Prospective Register of Systematic Reviews (PROSPERO) ID: CRD42022376552. Randomized controlled trials, prospective comparative studies, prospective single‐group (with pre‐ and post‐training assessment) or consensus studies that reported on the development, validation or usage of assessment tools of surgical performance in minimally invasive gynecological surgery, were included. Three independent assessors assessed study setting and validity evidence according to a contemporary framework of validity, which was adapted from Messick's validity framework. Methodological quality of included studies was assessed using the modified medical education research study quality instrument (MERSQI) checklist. Heterogeneity in data reporting on types of tools, data collection, study design, definition of expertise (novice vs. experts) and statistical values prevented a meaningful meta‐analysis. Results: A total of 19 746 titles and abstracts were screened of which 72 articles met the inclusion criteria. A total of 37 different assessment tools were identified of which 13 represented manual global assessment tools, 13 manual procedure‐specific assessment tools and 11 automated performance metrices. Only two tools showed substantive evidence of validity. Reliability and validity per tool were provided. No assessment tools showed direct correlation between tool scores and patient related outcomes. Conclusions: Existing objective assessment tools lack evidence on predicting patient outcomes and suffer from limitations in transferability outside of the research environment, particularly for automated performance metrics. Future research should prioritize filling these gaps while integrating advanced technologies like kinematic data and AI for robust, objective surgical skill assessment within gynecological advanced surgical training programs. [ABSTRACT FROM AUTHOR]

Previous studies have reported the clinical utility of the LMA® Supreme™ (LMA Supreme) in laparoscopic surgery under general anesthesia, but there has been limited research on the effectiveness of the self-pressurized Air-Q® (Air-Q) in this clinical context. This study assessed the clinical performance of the Air-Q in laparoscopic gynecological surgeries by comparing its effectiveness, particularly in terms of oropharyngeal leak pressure (OLP), against that of the LMA Supreme. Fifty-two female patients (American Society of Anesthesiologists class I--II) scheduled for laparoscopic gynecologic surgery were randomly assigned to either the Air-Q group or the LMA Supreme group. The primary outcome was OLP, and secondary outcomes included the number of attempts required for device insertion, the time taken for insertion, difficulty of insertion, leakage rate, and complications associated with supraglottic airway device use. The Air-Q group exhibited a significantly lower OLP compared to the LMA Supreme group (19.5 ± 4.1 cmH2O vs. 23.2 ± 6.0 cmH2O, p = 0.011), with a mean difference of -3.8 cmH2O (95% confidence interval, -6.6 to -0.9 cmH2O). Analysis of secondary outcomes revealed no significant differences between the two groups. LMA Supreme could be preferred over Air-Q for airway management during general anesthesia in patients undergoing laparoscopic gynecologic surgery primarily due to its higher OLP. However, the Air-Q remains a viable alternative, exhibiting no significant differences in leakage rates compared to LMA Supreme. [ABSTRACT FROM AUTHOR]

• The Modified Obstetric Clavien-Dindo system and SaCOMS has utility to draw meaningful, quantitative conclusions regarding morbidity. • SaCOMS considers the impact of multiple morbidities and interventions for adverse outcomes providing more insight into the patient experience. • Application of the score to a cohort of PAS patients suggests potential benefit of gynecologic-oncology-led MDTs for PAS management. It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS), as there is no widely accepted consensus for the classification of maternal surgical morbidity. Many studies focus on the amount of blood products transfused or admission to intensive care units (ICU). However, these are dependent on local policies and available resources. It also gives an incomplete representation of the entire 'patient journey' after they leave the operating room. Subsequent repeat procedures for lower urinary track damage is arguably worse from the woman's perspective than a short stay on an intensive care unit (ICU) for observation. We suggest a version of the Clavien-Dindo morbidity classification specific to obstetrics. Then employ it to build a quantitative morbidity score which aims to reflect the whole 'patient experience' including the post-operative pathway. We then demonstrate the utility of this system in a cohort of women with Placenta Accreta Spectrum (PAS). The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a survey-based consultation of a panel of experts in PAS and retrospectively applied to a cohort of 54 women who underwent caesarean hysterectomy for PAS. Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the 'patient experience'. Application of the classification system to a single-centre PAS cohort suggested that surgery by gynecologic-oncology surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation. This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centered representation of morbidity. [ABSTRACT FROM AUTHOR]

Aim: The objective of this study was to evaluate the reliability and quality of videos on YouTube about labiaplasty procedures. Material and Methods: A search was carried out on YouTube using the search terms 'labiaplasty' and 'labia minora reduction'. The first 100 videos for each keyword were evaluated and 42 videos were analyzed. The distribution of video types was examined. The videos were scored by a five-member committee using the global quality scale (GQS) and modified DISCERN (mDISCERN) scales. Videos uploaded by physicians and academicians were classified as professional, and patients, commercial entities, and allied health personnel were classified as non-professional groups. Results: The mean mDISCERN score of all videos was 2.29±0.65, while the mean GQS score was 2.75±0.67. When professional and non-professional groups were compared, the mDISCERN and GQS scores were significantly higher in the professional group (p=0.017 and p=0.010, respectively). When surgical technique videos and videos providing information about the disease or surgery were compared, there was a significant difference in video power index (VPI), viewing rate, and number of comments (p=0.001, p=0.001, and p=0.003, respectively), while there was no significant difference in terms of mDISCERN and GQS scores. Weak negative correlations were observed between the mDISCERN score and VPI (rs=-0.326, p=0.037), between the GQS score and viewing rate (rs=-0.392, p=0.010), and between the GQS score and VPI (rs=-0.382, p=0.014). Conclusion: YouTube is not a reliable source of information about labiaplasty. Low-quality videos receive more engagement. Obstetrics and gynecology associations should produce content on YouTube about this subject. [ABSTRACT FROM AUTHOR]

Background: Our bodies have adaptive mechanisms to fasting, in which glycogen stored in the liver and muscle protein are broken down, but also lipid mobilisation is triggered. As a result, glycerol and fatty acids are released into the bloodstream, increasing the production of ketone bodies in liver. However, there are limited studies on the incidence of perioperative urinary ketosis, the intraoperative blood glucose changes and metabolic acidosis after fasting for surgery in non‐diabetic adult patients. Methods: We conducted a retrospective cohort study involving 1831 patients undergoing gynecologic surgery under general anesthesia from January to December 2022. Ketosis was assessed using a postoperative urine test, while blood glucose levels and acid–base status were collected from intraoperative arterial blood gas analyses. Results: Of 1535 patients who underwent postoperative urinalysis, 912 (59.4%) patients had ketonuria. Patients with ketonuria were younger, had lower body mass index, and had fewer comorbidities than those without ketonuria. After adjustments, younger age, higher body mass index and surgery starting late afternoon were significant risk factors for postoperative ketonuria. Of the 929 patients assessed with intraoperative arterial blood gas analyses, 29.0% showed metabolic acidosis. Multivariable logistic regression revealed that perioperative ketonuria and prolonged surgery significantly increased the risk for moderate‐to‐severe metabolic acidosis. Conclusion: Perioperative urinary ketosis and intraoperative metabolic acidosis are common in patients undergoing gynecologic surgery, even with short‐term preoperative fasting. The risks are notably higher in younger patients with lower body mass index. Optimization of preoperative fasting strategies including implementation of oral carbohydrate loading should be considered for reducing perioperative metabolic derangement due to ketosis. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse (POP) is a common condition and is thought to affect approximately 40% of women over the age of 50, with prevalence increasing with age. 1 in 10 women will undergo surgery during their lifetime. Symptomatic women can be offered supervized pelvic floor exercises supported by Specialist Pelvic Floor Physiotherapists, vaginal pessary management or surgical management. This article covers comprehensive assessment, preoperative considerations to support shared decision making, and clinical governance surrounding surgical management of prolapse. It also provides a summary of different surgical techniques for both vaginal and abdominal approach for prolapse. [ABSTRACT FROM AUTHOR]

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Diffuse uterine leiomyomatosis (DUL) is a prevalent leiomyoma variant in women of childbearing age, characterized by a uniformly enlarged uterus with numerous interconnected small myomas. Given that most DUL patients are in their reproductive years, treatments that preserve fertility are increasingly vital. This case report introduces an innovative hysteroscopic technique that forgoes uterine distension to remove multiple submucosal fibroids in a single procedure, maintaining endometrial integrity and fertility. A 27‐year‐old single woman experienced prolonged and heavier menstruation. Magnetic resonance imaging (MRI) scans showed an enlarged uterus with several round‐like masses in the uterine wall/submucosa. Addressing the patient's financial limitations and treatment preferences, a groundbreaking hysteroscopic surgery was performed using thoracic tissue forceps, alongside bedside ultrasonography, enabling fibroid excision without uterine distension. In total, 38 uterine fibroids were successfully excised without complications such as uterine perforation or hyponatremia. According to the FIGO classification system: three were type III, nine were type II, 15 were type I, and 11 were type 0. Postoperative follow‐up indicated normalized menstrual cycles, improved hemoglobin levels, and no recurrence of fibroids. A hysteroscopic examination 1 month after surgery revealed no significant fibroids or endometrial thickening. This case report underscores the effectiveness of a novel hysteroscopic surgical approach in treating DUL. This method eliminates the need for multiple staged surgeries and the risks of endometrial damage inherent in traditional techniques. It offers a minimally invasive, fertility‐preserving alternative for young DUL patients, marking a significant advancement in gynecologic surgery. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusions The objective of this study was to assess the impact of the coronavirus pandemic on gynecology surgical training.A national cross‐sectional online survey was distributed to all trainees and trainers in the higher specialist training program for obstetrics and gynecology in Ireland. The survey consisted of questions on topics which included: the volume of surgical procedures performed before and since the pandemic, confidence in performing various gynecologic procedures before and since the pandemic and questions regarding the impact of the pandemic on wellbeing and work practices.Trainers and trainees experienced a significant reduction in operative volumes for most procedure types. Analysis showed a significant reduction in the number of minor procedures performed by trainees (z = −2.7, P = 0.007) and a significant reduction in the number of all procedure types performed by trainers (minor procedures z = −3.78, P = <0.001; intermediate procedures z = −4.48, P = < 0.001; major procedures z = −3.69, P = < 0.001). Respondents reported they had less time for research and audit, were less able to attend courses or conferences and worried about the impact of their work on their families.In conclusion, this study has highlighted the current difficulties facing surgical trainees in gynecology because of the COVID‐19 pandemic. These challenges have compounded an already challenging training environment for gynecology trainees. Efforts must be made to continue to provide high‐quality tailored training to ensure the development of the next generation of gynecologic surgeons. [ABSTRACT FROM AUTHOR]

Purpose: Hysterectomy is a common gynecological surgery associated with significant postoperative discomfort and extended hospital stays. Enhanced recovery after surgery (ERAS), a multidisciplinary approach, has emerged as a strategy aimed at improving perioperative outcomes and promoting faster patient recovery and satisfaction. This meta-analysis aimed to evaluate the impact of ERAS protocols on clinical outcomes, such as hospital stay length, readmission rates, and postoperative complications, in patients undergoing gynecological hysterectomy. Methods: Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted. Databases including PubMed, Embase, and Cochrane library were searched for relevant studies published up to January 31, 2023. A total of seventeen studies were selected based on predefined eligibility and exclusion criteria. Meta-analysis was carried out using a random-effects model with the STATA SE 14.0 software, focusing on outcomes like length of hospital stay, postoperative complications, and readmission rates. Results: ERAS protocols significantly reduced the length of hospital stays and incidence of postoperative complications such as ileus, without increasing readmission rates or the level of patient-reported pain. Notable heterogeneity was observed among included studies, attributed to the variation in patient populations and the specificity of the documented study protocols. Conclusion: The findings underscore the effectiveness of ERAS protocols in enhancing recovery trajectories in gynecological hysterectomy patients. This reinforces the imperative for broader, standardized adoption of ERAS pathways as an evidence-based approach, fostering a safer and more efficient perioperative care paradigm. [ABSTRACT FROM AUTHOR]

To evaluate plaintiff and defendant characteristics associated with iatrogenic genitourinary (GU) trauma litigation and outcomes of closed claims. LexisNexis was queried in April 2023 using terms related to GU organs and injury, and manually reviewed for iatrogenic cases. Case details including defendant, organ involvement, and legal outcome were obtained. Multinomial regression analysis was performed to identify factors associated with outcome. Four hundred ten cases involving 611 defendants were identified, with the ureter the most commonly affected organ (202/410, 49.3%). Most cases involved adult plaintiffs (380, 92.7%) and resulted in favor of the defense (227, 55.4%). Injuries resulted most frequently from gynecologic surgeries (179, 43.7%). Defendants were most commonly obstetricians/gynecologists (243/611, 39.8%) and urologists (168, 27.5%). Penile (OR 6.3 [95% CI 2.5-16.1]) and urethral (OR 4.8 [2.0-11.7]) injuries were associated with greater odds of a plaintiff verdict relative to ureter injury. A plaintiff verdict was also more likely when defendants were academic hospitals compared to individual practitioners (OR 4.3 [1.9-9.9]). In cases ruling in favor of the plaintiff, indemnity payments were larger when the defendants were comprised of individual practitioners compared to a hospital or medical group (median $549,613 vs $250,000, P <.001). Urologists may be involved in medical malpractice lawsuits for iatrogenic injury even when they are uninvolved in the index procedure. Most cases that reach litigation result in defense verdicts regardless of the GU organ injured. Defendant characteristics associated with plaintiff verdicts are more nuanced, and providers should be aware of potential downstream effects of litigation. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to develop a web‐based dynamic prediction model for postoperative nausea and vomiting (PONV) in patients undergoing gynecologic laparoscopic surgery. Methods: The patients (N = 647) undergoing gynecologic laparoscopic surgery were included in this observational study. The candidate risk‐factors related to PONV were included through literature search. Lasso regression was utilized to screen candidate risk‐factors, and the variables with statistical significance were selected in multivariable logistic model building. The web‐based dynamic Nomogram was used for model exhibition. Accuracy and validity of the experimental model (EM) were evaluated by generating receiver operating characteristic (ROC) curves and calibration curves. Hosmer–Lemeshow test was used to evaluate the goodness of fit of the model. Decision curve analysis (DCA) was used to evaluate the clinical practicability of the risk prediction model. Results: Ultimately, a total of five predictors including patient‐controlled analgesia (odds ratio [OR], 4.78; 95% confidence interval [CI], 1.98–12.44), motion sickness (OR, 4.80; 95% CI, 2.71–8.65), variation of blood pressure (OR, 4.30; 95% CI, 2.41–7.91), pregnancy vomiting history (OR, 2.21; 95% CI, 1.44–3.43), and pain response (OR, 1.64; 95% CI, 1.48–1.83) were selected in model building. Assessment of the model indicates the discriminating power of EM was adequate (ROC‐areas under the curve, 93.0%; 95% CI, 90.7%–95.3%). EM showed better accuracy and goodness of fit based on the results of the calibration curve. The DCA curve of EM showed favorable clinical benefits. Conclusions: This dynamic prediction model can determine the PONV risk in patients undergoing gynecologic laparoscopic surgery. [ABSTRACT FROM AUTHOR]

To examine the association between objectively-measured preoperative physical activity with postoperative outcomes and recovery milestones in patients undergoing gynecologic oncology surgeries. Prospective cohort study of patients undergoing surgery with gynecologic oncologists who wore wearable actigraphy rings before and after surgery from 03/2021–11/2023. Exposures encompassed preoperative activity intensity (moderate- and vigorous-intensity metabolic equivalent of task-minutes [MAVI MET-mins] over seven days) and level (average daily steps over seven days). Intensity was categorized as <500, 500–1000, and >1000 MAVI MET-mins; level categorized as <8000 and ≥8000 steps/day. Primary outcome was 30-day complications. Secondary outcomes included reaching postoperative goal (≥70% of recommended preoperative intensity and level thresholds) and return to baseline (≥70% of individual preoperative intensity and level). Among 96 enrolled, 87 met inclusion criteria, which constituted 39% (n = 34) with <500 MET-mins and 56.3% (n = 49) with <8000 steps preoperatively. Those with <500 MET-mins and <8000 steps had higher ECOG scores (p = 0.042 & 0.037) and BMI (p = 0.049 & 0.002) vs those with higher activity; all other perioperative characteristics were similar between groups. Overall, 29.9% experienced a 30-day complication, 29.9% reached postoperative goal, and 64.4% returned to baseline. On multivariable models, higher activity was associated with lower odds of complications: 500–1000 MET-mins (OR = 0.26,95%CI = 0.07–0.92) and >1000 MET-mins (OR = 0.25,95%CI = 0.07–0.94) vs <500 MET-mins; ≥8000 steps (OR = 0.25,95%CI = 0.08–0.73) vs <8000 steps. Higher preoperative activity was associated fewer days to reach postoperative goal. Patients with high preoperative activity are associated with fewer postoperative complications and faster attainment of recovery milestones. Physical activity may be considered a modifiable risk factor for adverse postoperative outcomes. • Higher preoperative physical activity is associated with fewer complications & shorter recovery. • Higher preoperative physical activity led to fewer complications in patients undergoing laparotomy. • Patients with <500 MET-mins over 7 days preoperatively had higher complication rates. • Patients with <8000 steps per day preoperatively had higher complication rates. • Patients with higher preoperative activity reached postoperative goal faster. [ABSTRACT FROM AUTHOR]

Recent evidence suggests that the fimbriated end of the fallopian tube harbors the precursor cells for many high-grade ovarian cancers, opening the door for development of better screening methods that directly assess the fallopian tube in women at risk for malignancy. Previously we have shown that the karyometric signature is abnormal in the fallopian tube epithelium in women at hereditary risk of ovarian cancer. In this study, we sought to determine whether the karyometric signature in serous tubal intraepithelial carcinoma (STIC) is significantly different from normal, and whether an abnormal karyometric signature can be detected in histologically normal tubal epithelial cells adjacent to STIC lesions. The karyometric signature was measured in epithelial cells from the proximal and fimbriated portion of the fallopian tube in fallopian tube specimens removed from women at: 1) average risk for ovarian cancer undergoing surgery for benign gynecologic indications (n = 37), 2) hereditary risk of ovarian cancer (germline BRCA alterations) undergoing risk-reducing surgery (n = 44), and 3) diagnosed with fimbrial STICs (n = 17). The karyometric signature in tubes with fimbrial STICs differed from that of tubes with benign histology. The degree of karyometric alteration increased with increasing proximity to fimbrial STICs, ranging from moderate in the proximal portion of the tube, to greatest in both normal appearing fimbrial cells near STICs as well as in fimbrial STIC lesions. These data demonstrate an abnormal karyometric signature in STICs that may extend beyond the STIC, potentially providing an opportunity for early detection of fallopian tube neoplasia. • Karyometric assessment reveals a signature that is abnormal in serous tubal intraepithelial carcinoma (STIC). • The abnormal karyometric signature extends to histologically normal fallopian tube epithelial cells beyond the STIC. • An abnormal karyometric signature in the fallopian tube has potential as a target for ovarian cancer screening. [ABSTRACT FROM AUTHOR]

Objectives: Enhanced recovery after surgery (ERAS) protocols provide well-known benefits in the immediate recovery with a shorter length of stay (LOS) and also in gynecological surgery. However, the impact of ERAS has not been clearly showed yet regarding long-term consequences and health-related quality of life (HRQL). The aim of this study was to investigate the impact of ERAS on HRQL after hysterectomy for endometrial cancer. Design: An observational retrospective study with propensity score matching (PSM) was performed. Participants: We administered the SF-36 validated questionnaire to women underwent hysterectomy and lymph nodal staging before and after introducing ERAS protocol, getting, respectively, a standard practice (SP) and ERAS group. Settings: The study was conducted at the academic hospital. Methods: We collected demographic, clinical, surgical and postoperative data and performed a PSM of the baseline confounders. We administered the questionnaire 4 weeks after the surgery. The SF-36 measures HRQL using eight scales: physical functioning (PF), role physical (RLP), bodily pain (BP), general health (GH), vitality (Vt), social functioning (SF), role emotional (RLE) and mental health (MH). Results: After PSM, we enrolled a total of 154 patients, 77 in each group (SP and ERA). The two groups were similar in terms of age, BMI, anesthetic risk, Charlson comorbidity index (CCI), and surgical technique (minimally invasive vs. open access). Median LOS was shorter for ERAS group (5 vs. 3 days; p = 0.02), while no significant differences were registered in the rates of postoperative complications (16.9% vs. 17.4%; p = 0.66). Response rates to SF-36 questionnaire were 89% and 92%, respectively, in SP and ERAS group. At multivariate analyzes, the mean scores of SF-36 questionnaire, registered at 28 days weeks after surgery (range 26–32 days), were significantly higher in ERAS group for PF (73.3 vs. 91.6; p < 0.00), RLP (median 58.3 vs. 81.2; p = 0.02), and SF (37.5 vs. 58.3; p = 0.01) domains, when compared to SP patients. Limitations: Further follow-up was not possible due to the anonymized data derived from clinical audit. Conclusions: ERAS significantly increases the HRQL of women who underwent surgery for endometrial cancer. HRQL assessment should be routinely implemented in the ERAS protocol. [ABSTRACT FROM AUTHOR]

Objective: In Japan, perioperative prophylaxis of pulmonary embolism (PE) in gynecologic cancer patients with preoperative asymptomatic venous thromboembolism (VTE) has not been well established yet. The GOTIC-VTE trial was a prospective, multi-center, single-arm clinical trial to investigate the prevention of postoperative symptomatic PE onset by seamless anticoagulant therapy from the preoperative period to 4 weeks after surgery instead of using intermittent pneumatic compression. Methods: Anticoagulant therapy was started immediately after asymptomatic VTE diagnosis and stopped preoperatively according to the rules of each institution. Unfractionated heparin administration was resumed within 12 hours postoperatively, and this was followed by the switch to low-molecular-weight heparin and subsequently, edoxaban; this cycle was continued for 28 days. Primary outcome was the occurrence of symptomatic PE in 28 days postoperatively. Secondary outcomes were the incidence of VTE-related events in 28 days and 6 months postoperatively and protocol-related adverse events. Results: Between February 2018 and September 2020, 99 patients were enrolled; of these, 82 patients were assessed as the full analysis set, including 58 for ovarian cancer, fallopian tube, or peritoneal cancer; 21 for endometrial cancer; and 3 for cervical cancer. No symptomatic PE was observed within 28 days postoperatively; two patients had bleeding events (major bleeding and clinically relevant nonmajor bleeding) and three had grade 3 adverse events (increased alanine transaminase, aspartate aminotransferase, or gamma-glutamyl transferase). Conclusion: The multifaceted perioperative management for gynecologic malignancies with asymptomatic VTE effectively prevented postoperative symptomatic PE. [ABSTRACT FROM AUTHOR]

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]

An incisional hernia is a typical long-term consequence of abdominal surgery. The majority of surgeons advise that these hernias be repaired as soon as they are identified. As a result, there was a need to study the disease condition and its many manifestations, as well as to assess the level of awareness among the patients who came to us and to decide the appropriate treatment modality in our facility. The following operative procedures were adopted in our study: 1. Prosthetic mesh repair (onlay) 2. Anatomical suture repair 3. IPOM 4. Open PCST In our study the age of the patient ranges from 25 years to 70 years. The mean age was 48.36 years (SD ± 11.00). In our present series of 36 cases of incisional hernia, 23 were female patients (63.89%) and 13 were males (36.11%). The male: female ratio was found to be 1: 1.76. Laparotomy were a major contributing procedure for Incisional hernia comprising of 21 (58.3%) cases out of 36 Incisional hernia cases, followed by gynecological operations 12(33.4%) cases, 2(5.6%) case of Open Cholecystectomy and 1(2.8%) case of Open Appendicectomy. Out of gynecological surgeries, major contributing surgeries were LSCS 10(27.8%) cases, Hysterectomy 2(5.6%) cases. Incisional hernias have a maximum diameter of the hernial defect in our study 12 cm. 2 cases of small incisional hernias were repaired by IPOM. There were 36 cases of incisional hernia comprising whose maximum diameter of the hernial sac is between 5 to 10 cm. 30 of these cases were repaired by open onlay mesh repair. In these cases, laparotomy followed by adhesiolysis, reduction of content, onlay mesh placement and closure of abdominal incision with suture was done. There was one case of incisional hernia whose diameter was more than 12 cm where open PCST was attempted with sublay mesh repair. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Urinary system injuries may occur iatrogenically during some surgical procedures especially gynecological and obstetrical surgeries. Unfortunately, these injuries can lead to serious complications in patients. In this multicentric study, we aimed to review and report our experiences and results of urinary tract injuries identified during gynecological and obstetrical surgery. METHODS: We included women with urinary tract injuries during gynecological and obstetrical surgeries between January 2018 and October 2023 at four centers. Detailed data collected include patient demographics, surgical details, injury characteristics, diagnostic and treatment methods, timing of injury diagnosis and management reports of the patients. The incidence of bladder and ureter injuries was evaluated and the rate of intraoperative urological consultations was recorded. RESULTS: In a total of 328 patients with a median age of 47 years (24-90), urinary tract injuries were diagnosed, including 227 (69.2%) iatrogenic bladder injuries (IBI) and 101 (30.8%) iatrogenic ureteral injuries (IUI). These injuries were diagnosed in 299 patients (91.2%) during surgery and in 29 patients (8.8%) after the surgical procedure. We observed intraoperative detection rates of 71.9% for IBI and 28.1% for IUI. IBI (71.9%) was diagnosed significantly more frequently than IUI (28.1%) (p=0.001). Cesarean section resulted in significantly more frequent IBI, whereas tumor debulking surgeries resulted in more IUI (n=52, 56.5%) than the other types of procedures (p<0.001). CONCLUSION: Our study provides a comprehensive overview of iatrogenic urological injuries during gynecological and obstetrical surgeries. Although the bladder is the most frequently injured organ during gynecological and obstetric surgeries, early diagnosis and urological intervention are mandatory to prevent delayed complications. Surgeons must have a thorough understanding of the pelvic anatomy and appropriate surgical techniques to prevent iatrogenic injuries during surgery and ensure timely diagnosis and treatment of urinary tract injuries. [ABSTRACT FROM AUTHOR]

Distinguishing between leiomyosarcoma and benign uterine leiomyoma, as one of the common problems in reproductive age, brings a great challenge in dealing with patients. Clinical findings, imaging report, tumor markers, endometrial biopsy, and even age of the patients will not be helpful to make this distinction. So, the important question is when we should consider leiomyosarcoma probability? In this report, an unexpected case of leiomyosarcoma with a poor prognosis is presented. A 45-year-old female patient gravida 3 with complaint of hypermenorrhea from one year ago was presented to the gynecologic department. The patient did not mention anything special in her medical history. At last, a hysterectomy was planned due to her irreversible bothering symptom. The final histologic report was leiomyosarcoma in the smallest myomatous mass of the uterus, and her post-operation CT scan with contrast of abdomen-pelvic revealed several metastatic focuses. Uterine sarcomas as one of the most important causes of mortality worldwide have a low incidence and defining the standard treatment and the exact prognosis require further study. More definitive ways to differentiate benign uterine leiomyoma from leiomyosarcoma including genetic studies, specific imaging techniques, specific tumor markers, and investigating the method of intrauterine biopsy by flexible or robotic hysteroscopy are needed. [ABSTRACT FROM AUTHOR]

Background and Objectives: Postoperative nausea and vomiting (PONV) is a common issue for females undergoing gynecological surgeries, including those assisted by robotic systems. Despite available prophylactic measures, the incidence of PONV remains high, negatively impacting recovery and increasing healthcare costs. This study evaluates whether preoperative gum chewing reduces the need for anti-emetic drugs in females undergoing robot-assisted laparoscopic surgery for benign ovarian mass. Materials and Methods: This prospective, single-blinded, randomized controlled trial enrolled 92 adult females scheduled for robot-assisted laparoscopic surgery to treat benign ovarian mass. Following exclusions, the remaining participants were randomly assigned to either a gum-chewing group or a no-gum-chewing group. The gum-chewing group chewed sugar-free gum for 15 min in the holding area before surgery. The primary outcome measured was the need for anti-emetics to control PONV during the first hour in the post-anesthesia care unit (PACU). Secondary outcomes included the number of anti-emetic requests. No preemptive anti-emetics were administered during surgery. Results: Out of the initial 92 patients, 88 were included in the final analysis, with 44 in each group. The incidence of PONV requiring anti-emetics in the PACU was significantly lower in the gum-chewing group (79.5%) compared to the no-gum-chewing group (95.5%). Additionally, the number of anti-emetic requests was higher in the no-gum-chewing group. No postoperative complications such as tooth or jaw pain/injury or gastric content regurgitation were reported. Conclusions: Preoperative gum chewing for 15 min immediately before surgery significantly reduced the incidence of PONV in females undergoing robot-assisted laparoscopic surgery for benign ovarian mass. This simple, non-pharmacological intervention improved patient comfort and reduced the need for anti-emetic medications without any adverse effects. Further studies are needed to confirm these findings and to develop guidelines for incorporating preoperative gum chewing into clinical practice. [ABSTRACT FROM AUTHOR]

Aim. To explore the potential factors that influence the presentation and recovery of postoperative chylous ascites (CA) in gynecological malignancies. Methods. We reported two cases of postoperative CA following gynecological surgery and reviewed the clinical features of 140 patients from 16 relevant papers. Patients' clinicopathological characteristics, surgical approach, and management were summarized. The onset and resolution times of postoperative CA in different groups were analyzed separately. Results. The two patients in our report had recovery after conservative treatments. According to the literature review, the median time of onset of postoperative CA was 5 days (range, 0–75 days) after surgery. The median resolution time was 9 days (range, 2–90 days). Among patients, 87.14% of them had lymphadenectomy during gynecological surgeries, while 92.86% of the patients had resolution after conservative treatments. Conclusions. Lymphadenectomy during surgery may be relevant to the postoperative CA. Conservative management could be the initial choice for postoperative CA treatment. [ABSTRACT FROM AUTHOR]

Objective: Gynecology residents have self-reported deficits in preparation for surgical practice, particularly in robotic training. The primary source of surgical training is active participation in an operating room, which can be documented in a resident's case log. Educators and trainees may assume an institution's case volume reflects residents' participation, but there is no standard way to hold attending physicians accountable for surgical education, case-by-case. This study examined the percent of major gynecologic cases that allowed active trainee participation over 3 months at a major academic medical center. Materials and Methods: A baseline assessment of obstetrics/gynecology residents' participation in gynecologic surgical cases was conducted over 3 months at a large, urban academic medical center. All open and robotic gynecologic cases were recorded by the residency education team. Trainees were asked to document if a resident was present in a surgical case and that resident's level of participation in the procedure. Results: Of 324 open and robotic gynecologic surgeries, 74% were covered by residents. Of the 240 cases in which residents participated, 71% could be entered into clinical case logs, and 29% permitted minimal to no active participation. Thus, residents were only able to log active participation in 53% of all open and robotic gynecologic cases in the 3-month timeframe. Conclusions: Operative case volume at an academic medical center does not necessarily reflect resident participation and surgical training experience; there is a need to incorporate surgical-teaching skills into faculty-development programs and to emphasize the importance of active participation, case by case, in residency training further. (J GYNECOL SURG 20XX:000) [ABSTRACT FROM AUTHOR]

Introduction: Hysterectomy is one of the most common major gynecological surgeries, and it is performed for benign and malignant reasons. Currently, five types of hysterectomies are described: vaginal (VH), abdominal (AH), laparoscopic (LH), robotic, and vNOTES (vaginal natural orifice transluminal endoscopic surgery). This paper compares these two types of surgery in obese patients by analyzing the surgeries performed by our team. Materials and methods: The research was conducted from January 2022 to December 2023 at the Department of Gynecology and Obstetrics of the General Hospital in Zadar. The study included female patients aged 18–75 years with a BMI > 30 kg/m2, regardless of parity, who were operated on for benign pathology. Results: There were 24 patients included in total. One conversion was observed in the TLH group because of excessive bleeding. Median operative time (IQR) was significantly lower in the vNOTES group (p < 0.05) than in the TLH group 35 (10.9) vs 125 (74.0) min. Conclusion: The results concerning the duration of surgery, conversion rate, and postoperative bleeding and complications show that vNOTES hysterectomies seem to be feasible for obese patients. Further studies are needed to confirm these observations. [ABSTRACT FROM AUTHOR]

Background & Objectives: In the event that gynecologic cancer surgery (GC surgery) is going to be accompanied with extreme pain, many localized blocks will be provided. The quadratus lumborum block, often known as a QLB, is a fascial plane block that was developed relatively recently for the therapy of post-abdominal surgery discomfort. In the current study, a comparison is made between the effectiveness and safety of thoracic paravertebral block (TPVB) and quadratus lumborum block (QLB) in patients undergoing GC surgery. Methodology: In this prospective comparative randomized trial, fifty patients with scheduled GC surgery were split evenly between two groups: QLB group (n = 25) to receive bilateral QLB type-2, or TPVB group (n = 25) to receive TPVB. The VAS scores were recorded at 1, 2, 4, 6, 12, and 24 h following surgery, and served as the key indicator of patient outcomes. Secondary outcomes were; the time to first request for the analgesic, the patient satisfaction, and the total morphine consumed as rescue analgesic in 24 h. Results: At 2, 6, 12 and 24 h, the VAS scores of the QLB group were significantly lower than those of TPVB group. Only 12 (48%) of the QLB group patients required rescue morphine, compared to all patients in the TPVB group requiring it. QLB group showed more dermatomal distribution in comparison to the TPVB group. It took the TPVB group a much shorter time to demand their first painkiller (P = 0.001), and they also took significantly more total morphine (P = 0.001). An increased number of people in the QLB group reported satisfaction as a result of taking the analgesic. Conclusion: Quadratus lumborum block is a promising technique for postoperative analgesia for patients undergoing gynecological cancer surgery. This block provides relatively prolonged duration of pain relief, compared to thoracic paravertebral block. [ABSTRACT FROM AUTHOR]

Aim: Laparoscopic lateral suspension is a novel approach for repairing anterior and apical pelvic organ prolapse (POP). According to integral theory, urinary symptoms and pelvic pain are believed to originate from suspensory ligaments. We aimed to investigate the objective and subjective outcomes of adding sacroterine plication to apical prolapse surgery. Methods: Sixty patients with Grade 2 or higher symptomatic apical POP were included in the study. The study sample was categorized into two groups: Group 1 underwent lateral suspension and Group 2 underwent lateral suspension and sacroterine plication. Anatomical cure was defined separately for the apical and anterior compartments as POP‐Q scores for sites C and Ba of less than −1 cm for each compartment. A subjective cure was defined as the absence of bulge symptoms. Patient satisfaction, sexual function, prolapse‐related quality of life, voiding dysfunction, nocturia, and constipation were assessed. Results: In Group 1, anatomical cure rates for apical and anterior prolapse were 100% and 70%, respectively (p <0.001). In Group 2, these rates were 100% for apical prolapse and 73.3% for anterior prolapse (p <0.001). The subjective cure was 96.6% in both groups. Furthermore, improvement in sexual and urinary symptoms was more significant in the group that underwent sacroterine plication (p <0.001). Conclusions: The additional sacroterine plication (shortening) procedure with lateral suspension proved to be an effective and successful surgical approach for apical prolapse. Its routine addition to existing lateral suspension surgery can contribute significantly to the improvement of urinary and prolapse symptoms. [ABSTRACT FROM AUTHOR]

Objective: This prospective study investigated the feasibility of performing laparoscopic pelvic surgery under spinal anesthesia and analyzed the intraoperative side effects, like pain, nausea, and vomitus, of 915 patients. Methods: The implementation and performance of laparoscopic surgery under local anesthesia on 915 patients (out of a total of 3212 who underwent laparoscopic pelvic surgery under spinal anesthesia) were analyzed in relation to BMI (body mass index), obesity, pain during surgery, amount of intraperitoneal mmHg CO2 gas pressure, and surgical complications. Results: BMI > 30, intra-abdominal adhesions, increased duration of the operation, bleeding, and increased intraperitoneal CO2 pressure were statistically significant as the main causes of pain during laparoscopic surgery under spinal anesthesia. Underweight patients, on the other hand, had less pain when intra-abdominal pressure increased compared to those of normal weight. The appearance of pain, nausea, and vomitus occurred in 10.3% of patients, and these events were easy to manage and treat. They did not affect the surgeon's work or the course of the operation. Conclusions: In light of these observations, we are proposing spinal anesthesia for laparoscopic surgery as the first choice in patients who have no contraindications. To the best of our knowledge, this clinical study constitutes the largest clinical observation and dataset concerning spinal anesthesia in laparoscopic pelvic surgery. Trial registration: ISRCTN38987, 10 December 2019. [ABSTRACT FROM AUTHOR]

To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. Patients undergoing laparotomy for a gynecologic oncology surgery between January–June 2017 (pre-SSIPB) and between January 2018–December 2020 (post-SSIPB) were compared using t -tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients. [Display omitted] • A Surgical Site Infection Prevention Bundle (SSIBP) requires coordination between healthcare providers. • Evaluating the implementation of a SSIBP in gynecologic oncology patients is challenging. • SSIPB Implementation is associated with improved surgical outcomes: shorter length of stay and fewer infections. [ABSTRACT FROM AUTHOR]

The aim of this study is to describe management and survival in adult patients with malignant ovarian germ cell tumors (MOGCT) undergoing surgery by general gynecologists (GG) versus gynecologic oncologists (GO). This is a population-based retrospective cohort study, including patients (age ≥ 18 years old) with MOGCT identified in the provincial cancer registry of Ontario, (1996–2020). Baseline characteristics, surgical and chemotherapy treatment were compared between those with surgery by GG or GO. Cox proportional hazards (CPH) model was used to determine if surgeon specialty was associated with overall survival (OS). Overall, 363 patients were included. One-hundred and sixty (44%) underwent surgery by GO and 203 (56%) by GG. There were higher rates of stage II-IV in the GO group (27.5% vs 3.9%, p < 0.001, and higher proportion of chemotherapy (64.4% vs 37.4%, p < 0.0001). Five-year OS was 90% and 93% in the GO vs GG groups, respectively (p = 0.39). CPH model showed factors associated with increased risk of death were older age at diagnosis (HR 1.09, 95% CI 1.07–1.12) and chemotherapy (HR 3.12, 95% CI 1.44–6.75). Surgeon specialty was not independently associated with all-cause death (HR 1.04, 95% 0.51–2.15, p = 0.91). In this group of MOGCT, 5-year OS was not significantly different between patients having surgery by GO compared to GG. Nevertheless, survival rates were lower than expected in the GG group despite their low-risk features. Further exploration is warranted regarding the reasons for this and whether patients with suspected MOGCT may benefit from early assessment by GO for optimal management. • In adult patients with MOGCT, stage of disease is the only factor associated with having surgery by gynecologic oncologist. • No difference in overall survival between individuals having surgery by gynecologic oncologist and general gynecologist. • Patients undergoing surgery by general gynecologist had lower survival than expected, despite their low-risk features. • Further exploration is needed to determine if individuals with suspected MOGCT should be referred for GO for management. [ABSTRACT FROM AUTHOR]

Hypothermia is highly common in patients undergoing gynecological surgeries under general anesthesia, so the length of hospitalization and even the risk of mortality are substantially increased. Our aim was to develop a simple and practical model to preoperatively identify gynecological surgery patients at risk of intraoperative hypothermia. In this retrospective study, we collected data from 802 patients who underwent gynecological surgery at three medical centers from June 2022 to August 2023. We further allocated the patients to a training group, an internal validation group, or an external validation group. The preliminary predictive factors for intraoperative hypothermia in gynecological patients were determined using the least absolute shrinkage and selection operator (LASSO) method. The final predictive factors were subsequently identified through multivariate logistic regression analysis, and a nomogram for predicting the occurrence of hypothermia was established. A total of 802 patients were included, with 314 patients in the training cohort (mean age 48.5 ± 12.6 years), 130 patients in the internal validation cohort (mean age 49.9 ± 12.5 years), and 358 patients in the external validation cohort (mean age 47.6 ± 14.0 years). LASSO regression and multivariate logistic regression analyses indicated that body mass index, minimally invasive surgery, baseline heart rate, baseline body temperature, history of previous surgery, and aspartate aminotransferase level were associated with intraoperative hypothermia in gynecological surgery patients. This nomogram was constructed based on these six variables, with a C-index of 0.712 for the training cohort. We established a practical predictive model that can be used to preoperatively predict the occurrence of hypothermia in gynecological surgery patients. Clinical trial registration: chictr.org.cn , identifier ChiCTR2300071859. • How can the occurrence of intraoperative hypothermia be predicted before surgery in gynecological surgery patients? • To address this issue, we conducted a multicenter cohort study of 802 patients who underwent gynecological surgery. • A powerful model was established for the early identification of patients prone to intraoperative hypothermia. [ABSTRACT FROM AUTHOR]

Simple Summary: The impact of a prior cervical excisional procedure on the oncologic outcomes of patients with early-stage cervical cancer undergoing radical hysterectomy is not established. Smaller retrospective studies suggest that conization prior to the performance of radical hysterectomy may be associated with lower risk of tumor relapse, especially for patients undergoing minimally invasive hysterectomy. We utilized a large hospital-based database and identified patients with FIGO 2009 stage IB1 disease who had primary surgical treatment. Approximately one in three patients had a prior excisional procedure performed within 3 months of radical surgery. We demonstrated that the performance of an excisional procedure prior to radical hysterectomy may be associated with better overall survival. For patients who had a prior excisional procedure, minimally invasive surgery was not associated with worse overall survival compared to laparotomy even after controlling for confounders. Objective: To investigate the impact of a prior cervical excisional procedure on the oncologic outcomes of patients with apparent early-stage cervical carcinoma undergoing radical hysterectomy. Methods: The National Cancer Database (2004–2015) was accessed, and patients with FIGO 2009 stage IB1 cervical cancer who had a radical hysterectomy with at least 10 lymph nodes (LNs) removed and a known surgical approach were identified. Patients who did and did not undergo a prior cervical excisional procedure (within 3 months of hysterectomy) were selected for further analysis. Overall survival (OS) was evaluated following the generation of Kaplan–Meier curves and compared with the log-rank test. A Cox model was constructed to control a priori-selected confounders. Results: A total of 3159 patients were identified; 37.1% (n = 1171) had a prior excisional procedure. These patients had lower rates of lymphovascular invasion (29.2% vs. 34.9%, p = 0.014), positive LNs (6.7% vs. 12.7%, p < 0.001), and a tumor size >2 cm (25.7% vs. 56%, p < 0.001). Following stratification by tumor size, the performance of an excisional procedure prior to radical hysterectomy was associated with better OS even after controlling for confounders (aHR: 0.45, 95% CI: 0.30, 0.66). The rate of minimally invasive surgery was higher among patients who had a prior excisional procedure (61.5% vs. 53.2%, p < 0.001). For these patients, performance of minimally invasive radical hysterectomy was not associated with worse OS (aHR: 1.37, 95% CI: 0.66, 2.82). Conclusions: For patients undergoing radical hysterectomy, preoperative cervical excision may be associated with a survival benefit. For patients who had a prior excisional procedure, minimally invasive radical hysterectomy was not associated with worse overall survival. [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]

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]

Introduction: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure‐specific simulation skills, vs usual training, result in improved operative competence. Material and methods: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self‐confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). Clinicaltrials.gov: Registration no. NCT05887570. Results: We randomized 83 residents to intervention or control and 55 completed the trial (2011–23). Baseline characteristics were similar, except for more fourth‐year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2–16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8–22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self‐confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. Conclusions: Compared to usual training, procedure‐specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters. [ABSTRACT FROM AUTHOR]

Introduction: Salpingitis is caused by ascending microbes from the lower reproductive tract and contributes to tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. The aim of this study was to analyze if the risk for complications and dissatisfaction after hysterectomy and adnexal surgery was increased in women reporting previous salpingitis. Material and methods: This is an observational cohort study including women undergoing gynecologic surgery from 1997 to 2020, registered in the Swedish National Quality Register of Gynecologic Surgery (GynOp). Patient‐reported previous salpingitis was the exposure. Complications up to 8 weeks and satisfaction at 1 year postoperatively were the outcomes. Multivariable logistic regression and ordinal regression were performed. Results were adjusted for potential confounders including age, body mass index, smoking and year of procedure as well as endometriosis and previous abdominal surgery. Multiple imputation was used to handle missing data. Results: In this study, 61 222 women were included, of whom 5636 (9.2%) women reported a previous salpingitis. There was an increased risk for women reporting previous salpingitis in both the unadjusted and fully adjusted models to have complications within 8 weeks of surgery (adjusted odds ratio [aOR] 1.22, 95% confidence interval [CI] 1.14–1.32). The highest odds ratios were found for bowel injury (aOR 1.62, 95% CI 1.29–2.03), bladder injury (aOR 1.52, 95% CI 1.23–1.58), and postoperative pain (aOR 1.37, 95% CI 1.22–1.54). Women exposed to salpingitis were also more likely to report a lower level of satisfaction 1 year after surgery compared with unexposed women (aOR 0.87, 95% CI 0.81–0.92). Conclusions: Self‐reported salpingitis appears to be a risk factor for complications and dissatisfaction after gynecologic surgery. This implies that known previous salpingitis should be included in the risk assessment before gynecologic procedures. [ABSTRACT FROM AUTHOR]

Background: Malignant struma ovarii (MSO) is a very rare disease in which thyroid cancer originates from the ovary. Because it is rare for endocrinologists to encounter patients with MSO, endocrinologists may have a limited understanding of the disease. Therefore, we analyzed and introduced its incidence and clinical course in a tertiary hospital in Korea. Methods: We retrospectively investigated the clinical data of 170 patients who underwent surgery for struma ovarii at the Department of Obstetrics and Gynecology of Samsung Medical Center from 1994 to May 2023. Results: Among 170 patients with struma ovarii, 15 (8.8%) were diagnosed with MSO. The median age of patients with MSO was 48 years (range, 30 to 74), and the median tumor size was 3.3 cm (range, 0.5 to 11.0). Papillary thyroid carcinoma (46.7%) was the most common subtypes followed by follicular thyroid carcinoma (26.7%). All patients were diagnosed after surgery, with no predictions from preoperative imaging. The surgical extent of gynecological surgery was variable. Four patients (26.7%) underwent thyroidectomy for thyroid cancer, while one underwent total thyroidectomy and radioactive iodine therapy for MSO with peritoneal metastasis. Except for one patient who underwent hemithyroidectomy, thyroid stimulating hormone suppression therapy was performed in four patients. Only 53% of MSO patients were consulted by an endocrinologist. With a median follow-up period of 33 months (range, 4 to 156), 11 patients remained disease-free, one experienced progression with peritoneal seeding, and the remaining one was in treatment. There have been no recurrences or deaths due to MSO. Conclusion: An endocrinologist should be involved in establishing a therapeutic plan for MSO, for which the overall prognosis is generally favorable. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to evaluate the sexual function and quality of life in female patients diagnosed with stress urinary incontinence (SUI) and pelvic organ prolapse (POP) after undergoing transobturator tape (TOT) or TOT with POP surgery and perineoplasty. Material and Methods: This prospective study population (n=86) consisted of sexually active women who had been diagnosed with SUI. Forty-six patients diagnosed with SUI with no POP (group 1) underwent TOT procedure only. Forty patients had a diagnosis of stage 2 and higher POP, based on POP quantification system with SUI (group 2). The second group was randomized as TOT-POP surgery (n=20) and TOT-POP surgery with perineoplasty (n=20). Prior to and six months after the surgical procedure, all female participants underwent assessment using the validated Urinary Distress Pre-Operative Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Pelvic Organ Prolapse Incontinence Sexual Questionnaire (PISQ). Results: Post-operative IIQ-7 and UDI-6 scores were significantly lower for all three groups compared to the preoperative period, while a significant increase was observed in PISQ scores (p<0.01). The dissimilarity in preoperative and postoperative IIQ-7 and UDI-6 scores exhibited comparable results across the groups, whereas the variance in PISQ scores was notably greater in the TOT + POP surgery + perineoplasty group (p=0.03). Conclusion: Women with SUI or SUI with POP have better quality of life and sexual dysfunction after surgery. Perineoplasty may enhance sexual life in patients with perineal defect and vaginal enlargement. [ABSTRACT FROM AUTHOR]