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Background: Previous reviews on hysterectomy versus uterine‐sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned. Objectives: To provide up‐to‐date evidence by examining only studies investigating techniques currently in use for POP repair. Search Strategy: MEDLINE and Embase databases were searched from inception to January 2023. Selection Criteria: We included randomized and non‐randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded. Data Collection and Analysis: A random effect meta‐analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI). Main Results: Thirty‐eight studies were included. Hysterectomy and uterine‐sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74–1.17), intraoperative major (OR 1.34; 95% CI 0.79–2.26) and minor (OR 1.38; 95% CI 0.79–2.4) complications, postoperative major (OR 1.42; 95% CI 0.85–2.37) and minor (OR 1.18; 95% CI 0.9–1.53) complications, and objective (OR 1.38; 95% CI 0.92–2.07) or subjective (OR 1.23; 95% CI 0.8–1.88) success. Uterine preservation was associated with a shorter operative time (−22.7 min; 95% CI –16.92 to −28.51 min), shorter hospital stay (−0.35 days, 95% CI –0.04 to −0.65 days), and less blood loss (−61.7 mL; 95% CI –31.3 to −92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups. Conclusions: No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors. Synopsis: In women with indication for surgical management of pelvic organ prolapse, the decision to preserve or remove the uterus should be tailored on individual factors. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Vaginal cuff dehiscence post‐hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel infarction. Consider second‐look laparotomy in cases of uncertain bowel viability. Vaginal cuff dehiscence (VCD) is a rare but potentially life‐threatening complication following a hysterectomy characterized by the separation of the vaginal vault. This condition, which may result in vaginal evisceration (VE), presents a significant risk of pelvic contents, particularly the small bowel, protruding into the vagina. Early diagnosis and prompt surgical intervention are paramount to prevent severe complications, including bowel infarction, obstruction, and peritonitis. Although VCD and VE are rare, they require urgent surgical management to avoid adverse outcomes. We reported a case of small bowel evisceration in a woman with a history of total abdominal hysterectomy 6 months ago. VCD and VE are very rare but life‐threatening complications of hysterectomy. Discussing the symptoms with patients who have multiple risk factors is crucial to avoid severe sequels following hysterectomy. Based on our experience, performing a second‐look laparotomy is a reliable approach to ensure the viability of the intestinal loop. However, it will likely increase the risk of infection. [ABSTRACT FROM AUTHOR]

Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH). A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62). TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p =.001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p =.001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p =.001). For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy. [ABSTRACT FROM AUTHOR]

Purpose: Pelvic organ prolapse (POP) and overactive bladder (OAB) commonly affect the aging female population. We aimed to investigate the possible relationship between the two, as reflected by urodynamic studies. Methods: A retrospective analysis was conducted on women who underwent urodynamic studies at a university-affiliated tertiary medical center from January 2018 to January 2021. Women presenting with urge incontinence and diagnosed with detrusor overactivity (DO) were included in the study. Based on the presence or absence of a modified POP-Q ≥ grade 2, these women were categorized into two groups. Data on general demographics, clinical symptoms, and urodynamic findings were extracted and compared using SPSS. Results: During the study period, 949 urodynamic evaluations were performed. Of these, 303 (31.92%) reported urge incontinence. Out of this subset, 151 (49.83%) were diagnosed with DO. Within this group, 18 (11.9%) had POP, while 134 (88.1%) did not. The POP group had a notably higher incidence of prior vaginal hysterectomy and anterior colporrhaphy (p = 0.02 and p = 0.01, respectively). While most urodynamic parameters were similar between groups, there was a significant increase in hesitancy in the POP group (13 s vs 8 s, p = 0.03). There was a trend indicating a reduced median Q max (12 ml/s vs. 18 ml/s, p = 0.06) and an increased flow time (55 s vs 40 s, p = 0.08) in the POP group. Conclusion: The urodynamic profile of the POP group suggests an obstructive voiding pattern. Further longitudinal research is essential to fully understand the relationship between POP and OAB. [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: Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology. Material and methods: A retrospective single‐center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown‐rump length (CRL) of ≥40 mm (≥10 weeks' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables. Results: Median CRL of the 17 patients included was 54.1 mm (range: 40.0–85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6–15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250–2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy. Conclusions: Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs. [ABSTRACT FROM AUTHOR]

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II‐S (AGREE II‐S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German‐speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous‐hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered. [ABSTRACT FROM AUTHOR]

Objective: To explore the change trends in incidence and leading factors to peripartum hysterectomy (PH) at a regional tertiary medical center in northeast China. Methods: This was a retrospective observational study of all PH cases conducted at Shengjing Hospital between January 1, 2012 and December 31, 2021. Information on maternal characteristics of pregnancy and delivery, indications of PH, inventions before hysterectomy, complications, and maternal and neonatal outcomes obtained from the Shengjing Hospital Information System were analyzed. Results: Among a total of 157 553 deliveries, there were 127 cases of PH (overall PH incidence: 0.85/1000 deliveries); 120 patients (94.49%) underwent hysterectomy after cesarean section, and seven (5.51%) underwent vaginal delivery (P < 0.001). Abnormal placentation was the leading indication for PH (101, 79.53%), including placenta previa (PP) with placenta accreta spectrum (PAS) (93, 73.23%), PP alone (5, 3.94%), and PAS alone (3, 2.36%). Among the patients who underwent PH with abnormal placentation, 92.08% had at least one cesarean section (P < 0.001) and 20.19% had bladder injury (P = 0.044). All maternal deaths (n = 2) occurred in referral patients, and the maternal mortality rate was 1.57/100 hysterectomies. Conclusion: Abnormal placentation was the primary indication for PH. For such patients, adequate assessment of their condition and complete communication are strongly recommended. The identification of high‐risk groups for postpartum hemorrhage, timely and effective rescue, and referral are equally important for avoiding PH. Synopsis: Abnormal placentation is the primary indication for peripartum hysterectomy. Prenatal prevention, intrapartum monitoring, and timely control of postpartum hemorrhage are important in peripartum hysterectomy. [ABSTRACT FROM AUTHOR]

Objectives: To compare maternal outcome measures in surgical management of placenta accreta spectrum (PAS)—the modified one‐step conservative uterine surgery (MOSCUS), a new approach at Tu Du Hospital in Vietnam, versus cesarean hysterectomy, and to identify factors that appear to contribute to the successful outcome of the MOSCUS. Methods: This retrospective study was conducted at Tu Du Hospital in southern Vietnam between January 2019 and December 2020. The study enrolled all pregnant women at more than 28 weeks of pregnancy with a diagnosis of PAS who underwent either a cesarean hysterectomy or a uterus‐preserving approach using the MOSCUS method. Results: The prevalence of PAS at our single tertiary referral hospital was 0.4% (619 PAS cases/132 518 births) in 2 years. Among 296 patients, the surgical time duration, estimated blood loss, and red blood cell transfusion in the MOSCUS group (n = 217) were all significantly less than in the cesarean hysterectomy group (n = 79) (152.72 ± 42.23 vs 185.13 ± 58.22 min, 1000 vs 1500 mL, and 500 vs 710 mL, respectively). Intraoperatively, the rate of visceral injuries in the hysterectomy group was higher than that in the MOSCUS group (P < 0.001). However, the rate of postoperative infection was higher in the MOSCUS group than in the cesarean hysterectomy group (P = 0.012). Of a total of 217 cases managed using the MOSCUS management, 24 required a secondary hysterectomy; the success rate was 88.9% (95% confidence interval [CI] 84.3%–93.1%). Some of the primary factors associated with the success of MOSCUS included maternal age less than 35 years, planned surgery, severity of PAS, and estimated blood loss during surgery (odds ratio [OR] 5.16, 95% CI 1.96–13.59; OR 3.05, 95% CI 1.08–8.62; OR 3.62, 95% CI 1.19–10.98; and OR 49.66, 95% CI 11.16–221.02, respectively; P < 0.05). Conclusion: MOSCUS is an acceptable alternative to cesarean hysterectomy in many patients diagnosed with PAS. This new surgical management of PAS resulted in the preservation of the uterus, and a favorable outcome in nearly 9 out of 10 pregnant women. We believe that MOSCUS can be safely offered for the management of PAS in referral hospital settings. Synopsis: Using MOSCUS in the surgical assessment of placenta accreta spectrum helps preserve the uterus in nearly 9 out of 10 pregnant women with favorable outcomes. [ABSTRACT FROM AUTHOR]

Placenta accreta spectrum (PAS) disorder is one of the leading causes of peripartum maternal morbidity and mortality; its early identification during pregnancy is of utmost importance to ensure the optimal clinical outcome. The aim of the present study is to investigate the possible association of the presence and type/location of placenta previa on MRI with PAS and maternal peripartum outcome. One hundred eighty-nine pregnant women (mean age: 35 years; mean gestational age: 32 weeks) at high risk for PAS underwent a dedicated placental MRI. All women underwent a C-section within 6 weeks from the MRI. All MRIs were evaluated by two experienced genitourinary radiologists for presence, type (complete/partial vs. marginal/low lying), and location (anterior vs. anterior-posterior vs. posterior) of placenta previa. Statistical analysis was performed for possible association of type/location of previa with placental invasiveness and peripartum outcomes. Intraoperative information was used as a reference standard. Complete/partial previa was detected in 143/189 (75.6%) and marginal/low lying previa in 33/189 (17.5%) women; in 88/189 (46.6%) women, the placenta had anterior–posterior, in 54/189 (28.6%) anterior and in 41/189 (21.7%) posterior. Complete/partial previa had an at least 3-fold probability of invasiveness and was more frequently associated with unfavorable peripartum events, including massive intraoperative blood loss or hysterectomy, compared to low-lying/marginal placenta. Posterior placental location was significantly associated with lower rates of PAS and better clinical outcomes. In conclusion, the type and location of placenta previa shown with MRI seems to be associated with severity of complications during delivery and should be carefully studied. [ABSTRACT FROM AUTHOR]

To assess trends and differences in patient characteristics, complications, and distributions of hysterectomy for benign indications by benign gynecologists (BG) and gynecologic oncologists (GO). This retrospective cohort study identified patients undergoing hysterectomy for benign indications using the National Surgical Quality Improvement Program data from 2014 to 2021. Exclusions were made for gynecologic or disseminated cancers, ascites, non-gynecologic surgeons, and cesarean hysterectomies. Primary outcome was major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, andthromboembolic complications. Thirty-day readmissions, reoperations, and mortality were also analyzed. Propensity score matching was performed in a 1:1 match of GO to BG patients and was compared. Linear regressions assessed trends. Among 198,767 patients, 18% (n = 37,707) underwent hysterectomy for benign indications with GO. GO patients exhibited more risk factors for complications and differed significantly from BG patients in comorbidities and perioperative characteristics. Overall, GO patients had higher major complication rates (3.1% vs 2.2%, p < 0.001) and for several other composite complications. After matching, compared to BG, GO-performed hysterectomies had similar rates of major complications (3.0% vs 3.0%, p = 0.55) and no differences in other composite complications, except fewer reoperations (1.2 % vs 1.5%, p < 0.01) and wound complications (0.4% vs 0.5%, p = 0.02) in GO patients. Over the eight years, the percentage of GO-performed hysterectomy (β = 0.41, R2 = 0.71, p < 0.01) increased significantly whereas BG-performed surgeries decreased by the same magnitude. BG had a significant decrease in frail patients (β = −0.47, R2 = 0.90, p < 0.01), but GO did not (β = −0.36, R2 = 0.38, p = 0.10). GO are performing more hysterectomies for benign indications on higher-risk patients. However, on a matched cohort, risks of major complications were similar between GO and BG. • Gynecologic oncologists are performing more hysterectomy for benign indications. • Gynecologic oncologists' benign hysterectomies have higher risk factors and experience more major complications. • Similar complicate rates seen between gynecologic oncologist and benign gynecologist when risk factors are controlled. • Percentage of frail patients undergoing benign hysterectomies is decreasing over time. • There are implications for patient selection, resource management, and collaboration in benign surgeries by oncologists. [ABSTRACT FROM AUTHOR]

Objective: Aim of the study is to compare the efficacy of vessel sealing for securing pedicles in vaginal hysterectomy as compared to total laparoscopic hysterectomy in terms of operating time, perioperative Hb differences, time taken for ambulation, postoperative pain, hospital stay and Intra and Post-op complications. Method: This is a prospective randomized controlled clinical trial conducted at GMERS Medical College and Hospital, Sola, Ahmedabad over a period of about 3 years. A total of 102 patients were divided into 2 groups randomly. One group is operated by Vessel Sealing Device via Vaginally and other group is operated by total laparoscopic hysterectomy. Result: Significant reduction in operative time, post operative pain, pre and post-op Hb deficit, time taken for ambulation and hospital stay in Vaginal Hysterectomy with Vessel Sealer were found compared to Total laparoscopic hysterectomy. There was no significant difference in major intraoperative and post-operative complications. Conclusion: Vaginal Hysterectomy with Vessel Sealer is an effective alternative to Total Laparoscopic Hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS. Methods: A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy. Results: A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109–0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001). Conclusion: PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO. [ABSTRACT FROM AUTHOR]

Introduction: Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients. Methods: We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Results: Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively. Conclusion: Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients. [ABSTRACT FROM AUTHOR]

Out of the total cases of cervical cancer, brain metastases (BMs) are relatively rare, with an estimated incidence rate of 0.63% (range: 0.1%–2.2%). Additionally, BMs prognosis remains poor, and the average patient survival time following a BM diagnosis is 3 to 5 months. Few studies have addressed the effect of programmed cell death‐1 inhibitors against BMs in cervical cancer, although they are an established option for recurrent/metastatic disease. Hence, we report a case involving a 54‐year‐old post‐surgery patient with cervical cancer with a body mass index of 19.5 kg/m2 and Eastern Collaborative Oncology Group (ECOG) performance status of 3; the disease recurred with BMs 1 year later. Intensity‐modulated radiation therapy concurrent with temozolomide and bevacizumab was initiated, following which zimberelimab immunotherapy combined with anlotinib was administered to extend tumor control. The patient had a progression‐free survival duration of 10 months, the tumor response was assessed as a partial response based on the evaluation criteria for solid tumors (RECIST1.1), and the ECOG status improved to 1 after therapy. These findings suggest that immunotherapy‐based combination therapy following radiotherapy may be a good choice for patients with cervical cancer and BMs. [ABSTRACT FROM AUTHOR]

Purpose: Studies involving minimally invasive hysterectomy and robotic sacrocolpopexy have demonstrated safety and feasibility of same-day discharge. There are limited data, however, on same-day discharge outcomes for vaginal hysterectomy and pelvic reconstruction. This study aimed to compare 30 and 90-day surgical outcomes between same-day discharge versus overnight stay following vaginal hysterectomy and apical suspension. Patients and Methods: This retrospective study evaluated surgeries performed over two time periods. Overnight stay was standard between December 2018 and February 2020. Same-day discharge was standard from December 2020 to February 2022. All patients who underwent vaginal hysterectomy with apical suspension were included. The primary outcome was to determine if there was an increase in 30-day readmission rates. Secondary outcomes included emergency department visits and reoperations within 30 days, the previous variables at 90 days, and the rate for successful same-day discharge. Results: A total of 324 patients were analyzed over the 30 months: 149 (46%) in the overnight stay group and 175 (54%) in the same-day discharge group. At 30 days, no difference was found between groups for readmissions (2.7% vs 4.0%, p = 0.56), emergency department visits (14.8% vs 14.9%, p = 1.0), or reoperations (2.0% vs.1.7%, p = 1.0). At 90 days, outcomes were also similar. Same-day discharge as standard practice was successful in 80% of patients. Conclusion: In this retrospective two cohort study, the safety of same-day discharge following vaginal hysterectomy with apical suspension was demonstrated with no increased risk of 30 or 90-day readmissions, emergency visits, or reoperation rates. The majority (80%) of patients were discharged on the day of surgery, suggesting feasibility of this model. [ABSTRACT FROM AUTHOR]

Background: The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods: This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results: The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions: vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78) [ABSTRACT FROM AUTHOR]

Objective: Hysterectomy is a widely performed major gynecologic surgery. However, few studies have examined the outcomes of vaginal natural orifice transluminal endoscopic surgery (vNOTES) and compared them with those of conventional laparoscopic hysterectomy. This study assessed if vNOTES hysterectomy is both safe and feasible for patients with noncancerous conditions of the uterus. Materials and Methods: This comparative retrospective study was conducted in the department of obstetrics and gynecology at Al-Karak Governmental Hospital, Karak, Jordan. Data on hysterectomy cases were collected from hospital records for operations between January 2018 and January 2023. There were 2 groups of patients: a total laparoscopic hysterectomy (TLH) group and a vNOTES group. Data from each group were obtained on patients' demographics, indications for surgery, and intraoperative and postoperative parameters. Results: After exclusions, the TLH group had 44 cases and the vNOTES group had 16 cases. Both groups had similar general characteristics with the most-common indication for hysterectomy being fibroid uteri: ∼ ½ of TLH cases, compared to ∼1/3 of vNOTES cases. Patients who had TLH had significantly shorter surgery durations (151.7 ± 50.4 minutes), compared to patients who had vNOTES (176.3 ± 36.9 minutes); p = 0.044. vNOTES resulted in significantly longer hospital stays (1.8 ± 0.5 days) than TLH (1.5 ± 0.5 days); p = 0.029. Conclusions: The vNOTES approach is a novel technique which showed comparable outcomes to conventional laparoscopy. (J GYNECOL SURG 40:132) [ABSTRACT FROM AUTHOR]

Background: Our study aims to the compare the duration of post-operative analgesia, times of post-operative opioid consumption, post-operative sedation score, and haemodynamic changes between the groups on using 8mg Dexamethasone and 75 µgm clonidine as an adjuvant to 0.25% Ropivacaine in ultrasound-guided bilateral TAP block in patients undergoing total abdominal hysterectomy. Study design: Prospective, randomized, double blinded study with 56 patients were included and allocated using a -generated randomization code into: Group A (n=28 patients): Received USG guided bilateral TAP block with Injection Ropivacaine (0.5%) 20ml + Dexamethasone (8 mg) 2ml + Normal Saline 18 ml and Group B (n=28 patients) Received USG guided bilateral TAP block with Injection Ropivacaine (0.5%) 20ml + clonidine (75mcgs) 0.5 ml + Normal Saline 19.5 ml. Results: The duration of pain relief was highest (14.3 ± 4.7 hours) in group B patients compared to group A (11.1 ± 5.1 hours). The duration of analgesia provided by 75 mcg clonidine was statistically significant (p<0.001). Post-operative opioid consumption was higher in group A compared to group B which is statistically not significant. (P>0.05). There was also no significant difference in between the study groups for sedation scoring and haemodynamic changes. Conclusion: The addition of dexamethasone 8mg or clonidine 75 mcgs to 0.25% ropivacaine significantly prolongs the duration of analgesia and reduces postoperative opioids requirement, thereby facilitating early recovery and ambulation. On comparing, clonidine appears to be superior adjunct, in terms of pain relief. [ABSTRACT FROM AUTHOR]

• Closing the angles of the vaginal cuff reduces patients' perception of postop vaginal bleeding. • Intervention takes approximately 3.3 additional minutes. Determine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients' perception of postoperative bleeding after laparoscopic hysterectomy. Randomized controlled trial. University-based medical center. Females ages 18–60 undergoing laparoscopic hysterectomy. Patients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90–114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days. n = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0–5.0) v 2.0 (0–4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30–75) vs 50 mL (20–75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar. Independently suturing the vaginal cuff angles reduces patients' perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar. [ABSTRACT FROM AUTHOR]

Objective: To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in terms of feasibility and safety. Methods: A single‐center, observational, retrospective, cohort study was carried out including all patients undergoing TLH requiring manual vaginal morcellation for specimen extraction of large uteruses from January 2015 to August 2021 at the Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero‐Universitaria of Bologna, Bologna, Italy. Patients were divided into two groups according to the type of manual vaginal morcellation (contained or free), and compared in terms of demographic, clinical, and perioperative data. Results: In all, 271 patients were included: 186 (68.6%) in the contained morcellation group and 85 (31.4%) in the free morcellation group. The mean operative time was significantly lower in the contained morcellation group compared with the free morcellation group (median [interquartile range] 130 [45] vs. 155 [60] min; P < 0.001). No significant difference was found in complications related to the morcellation step, overall, intraoperative and postoperative complications, estimated blood loss, length of hospital stays, uterine weight, and rate of occult malignancy between the two groups. Conclusion: Contained vaginal manual morcellation of the uterus after total laparoscopic hysterectomy using a specimen retrieval bag appears to be a safe procedure with significantly lower operative time than free vaginal manual morcellation. SYNOPSIS: Contained vaginal morcellation of the uterus after total laparoscopic hysterectomy seems to be a safe procedure associated with reduced operative times. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effectiveness of modified total colpocleisis for advanced pelvic organ prolapse (POP) in elderly women and to assess the improvement in lower urinary tract symptoms (LUTS) of the patients. Methods: An observational cohort study was conducted, including 105 POP patients who underwent modified total colpocleisis between April 2020 and December 2022. The study analyzed the patients' demographic characteristics, perioperative outcomes, and follow‐up outcomes, including complications, remission of LUTS, satisfaction rates, and regret rates. Confirming the safety, durability, and patient satisfaction of modified total colpocleisis. Results: Most patients (95/105, 90.5%) had more than one comorbidity. Eighty‐six (81.9%) had a concomitant hysterectomy, the average operative time was 112.78 ± 34.92 min, with a median estimated bleeding of 50 mL (10–300 mL). Perioperative changes in hemoglobin and hematocrit were 11.64 ± 10.03 g/L and 3.87% ± 3.05%, respectively. Urinary retention was the most common complication (10/105, 9.5%). With a median follow up of 16 months (3–35 months), 101 patients (96.2%) reported satisfaction with the results of the procedure, with none reporting regret. Both subjective and anatomical recurrence rates were quite low (2.9% and 5.7%, respectively). Twenty‐three (21.9%) had de novo urinary incontinence, and the remaining LUTS such as frequent, urgent, hesitation, and difficulty emptying were significantly improved (P < 0.05). Conclusion: Modified total colpocleisis is an effective treatment option for elderly women with severe POP. This procedure can significantly improve several LUTS, and most de novo incontinence is mild and has a limited impact on patients' quality of life. Synopsis: Modified total colpocleisis is a safe, durable procedure with minimal complications, high patient satisfaction, and significant remission of lower urinary tract symptoms after surgery. [ABSTRACT FROM AUTHOR]

Objectives: To compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and transvaginal endoscopic hysterectomy (TVEH) for benign uterine diseases. Methods: This retrospective, cohort, interrupted time‐series study included patients who underwent TLH between January 2013 and September 2016 and TVEH between October 2016 and June 2020. Median difference regression was used to compare the hospital length of stay (LOS) and operative time between the groups. Risk difference regression was used to analyze the proportion of patients who developed postoperative fever or vaginal stump infection. Results: Of the total 171 patients enrolled, 101 and 70 underwent TVEH and TLH, respectively. The mean ages of patients in the TVEH and TLH groups were 46.49 and 46.17 years, respectively. No conversion was observed. Ureteric injury occurred in one patient in the TVEH group, whereas there was no organ injury in any of the patients in the TLH group. Compared with those in the TLH group, patients in the TVEH group had a significantly shorter median operative time, shorter hospital LOS, lower morphine use, and lower postoperative febrile morbidity rates. However, no significant difference was observed in the rate of vaginal stump infection between the groups. Conclusion: Given the shorter operative time, shorter hospital LOS, less febrile morbidity, and lower morphine use in patients with TVEH than in those with TLH, TVEH should be considered as an alternative hysterectomy procedure for benign uterine diseases. Synopsis: TVEH was associated with better surgical outcomes than TLH, and showed similar organ injury and conversion rates to those in TLH. [ABSTRACT FROM AUTHOR]

Objective: Aggressive Angiomyxoma (AA) of the vulva is a slow-growing mesenchymal tumour with a tendency to local invasion and recurrence. Case report: We report two cases of vulvoperineal masses that were diagnosed to be Aggressive Angiomyxomas after surgical excision. Both patients presented to the Gynaecology OPD of All India Institute of Medical Sciences, Bathinda, Punjab, India, in 2020 and 2022 with complaints of a mass coming out of introitus of three years duration and 14 years duration, respectively. The first patient was managed by surgical excision of the mass via abdominoperineal approach, while the second patient underwent vaginal hysterectomy along with the removal of the mass. Both patients were given GnRH analogues after the surgery to avoid any further recurrences and have been in remission on follow-ups so far. Conclusion: Due to its rare occurrence, clinicians should consider the possibility of AA while encountering patients with vulvovaginal masses to avoid misdiagnosis and delayed management. [ABSTRACT FROM AUTHOR]

Background: Subarachnoid blockade with local anaesthetics provide intense analgesia by segmental blockade of central neural axis but the duration is short lasting. Various drugs are administered intrathecally along with local anaesthetics to prolong the duration of action. Present study was aimed to study effects of intrathecal clonidine as an adjuvant with 0.5 % hyperbaric bupivacaine in vaginal hysterectomy under spinal anaesthesia at a tertiary hospital. Material and Methods: Present study was prospective, randomized double-blind, controlled, single center study, conducted in patients of age 45 - 65 years, normotensive, ASA grade I and II, scheduled for vaginal hysterectomy under spinal anaesthesia. Results: In this study 40 patients were enrolled. Hemodynamic variables (Pulse rate, systolic blood pressure & diastolic blood pressure) were studied. In present study, we noted that duration of onset to peak sensory block was 5.45 ± 0.50 min, duration of onset to motor block was 7.05 ± 0.22 min, duration of sensory block was 189.80 ± 6.49 min, duration of motor block was 247.28 ± 8.42 min & mean duration of post-operative analgesia was 495.93 ± 22.43 min. Number of analgesic injections required were 3 in majority patients. Visual analogue scale score was 0 at 1 hr., 2 hr., 3 hr. & 4 hr. while at 6 hr., 8 hr., 10 hr., 12 hr., 18 hr. & 24 hrs. median VAS was < 5. Bradycardia was noted in one patient and hypotension occurred in two patients, which were managed effectively. Overall incidence of side effects was low. Conclusion: Clonidine is a good adjuvant drug and its use intrathecally as an additive to bupivacaine extends the duration of spinal anaesthesia significantly, lowering the need to administer general anaesthesia if duration of surgery is prolonged. [ABSTRACT FROM AUTHOR]

Performing classical vaginal hysterectomy on patients with pelvic organ prolapse and cervical elongation can be challenging. Despite the difficulties and risks, it remains the safest and the best available option. We present an illustrated case of step-by-step vaginal hysterectomy management of pelvic organ prolapse with cervical elongation in a 42-year-old woman. [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: Ureteral injuries are the most feared complications of gynecological surgery and therefore intraoperative recognition is of the utmost importance. Intraoperative cystoscopy represents the diagnostics of choice to investigate ureteral patency thanks to the direct visualization of ureteral flows after administration of infusion mediums. In this study, we aimed to compare the diagnostic performance of saline versus mannitol intraoperative cystoscopy in terms of false negatives in a large cohort of patients. Methods: We retrospectively analyzed data of patients who underwent vaginal hysterectomy and high uterosacral ligament suspension for POP. Patients were divided in two groups based on the use of saline or mannitol medium for intraoperative cystoscopy. Postoperative daily control of serum creatinine was performed until discharge, as well as urinary tract imaging, in symptomatic patients. Results: A total of 925 patients underwent vaginal hysterectomy followed by high USL suspension for POP. Saline and mannitol medium were used in 545 patients and 380 patients respectively. Postoperative ureteral injuries were identified in 12 patients, specifically in 2% of the saline group and in 0.3% of the mannitol group. Conclusions: The use of mannitol instead of saline as a bladder distension medium was able to significantly reduce the occurrence of postoperative ureteral sequelae. [ABSTRACT FROM AUTHOR]

Study Objective: To investigate diverse hysterectomy techniques to determine their influence on patient outcomes, including pain levels, sexual function, anxiety, and quality of life. Of particular focus is the comparison between vessel sealing and traditional suturing in abdominal, vaginal, and laparoscopic hysterectomies. This study is unique in its comprehensive evaluation, considering patient satisfaction, recommendation rates, recovery times, and various other aspects. Method: Our prospective cohort study adhered to ethical guidelines, involving a meticulous assessment of patients, including medical history, anxiety levels, pelvic pain, sexual function, and quality of life. Surgical methods were explained to patients, allowing them to actively participate in the decision-making process. Sociodemographic information was collected, and exclusion criteria were applied. Hysterectomy methods included total abdominal hysterectomy (TAH), laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and a modified vaginal technique known as VH Mujas. Several parameters were recorded, including operation indications, uterine volume, hospital stay, operation duration, pre-operative and post-operative complications, and more. Results: In all groups, a statistically significant increase was found in pre-operative–post-operative FSFI sexual function values (p < 0.001). The patient's basal Beck Anxiety Scale scores significantly decreased following the decision for vaginal surgery, both in the VH and VH Mujas groups (p < 0.05). However, Beck Anxiety Scale scores at patients' initial assessments significantly increased following the decision for abdominal and laparoscopic surgery (p < 0.001). According to the results of the SF-36 quality of life assessment, an increase was observed in all post-operative quality of life parameters in patients who underwent surgery with different methods due to VH (p < 0.05). Conclusions: Our comprehensive comparison of hysterectomy techniques demonstrated that VH, particularly when utilizing the Mujas technique, outperforms other hysterectomy methods regarding patient safety and post-operative satisfaction but also offers the benefit of minimal invasiveness. Notably, this is reflected in improved quality of life, enhanced sexual function, lower pain scores, and favorable cosmetic results. The success of a hysterectomy procedure depends on precise indications, surgical planning, proper patient selection, and effective communication. This study emphasizes the significance of these factors in achieving optimal outcomes. The development of specialized vascular closure devices can further enhance the feasibility of vaginal hysterectomy, making it a preferable choice in gynecological surgery. The study contributes valuable insights into selecting the most suitable hysterectomy method for patients and optimizing their recovery. [ABSTRACT FROM AUTHOR]

Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. More than 90 uterus transplantations have been performed worldwide, mostly from living donors. Living-donor (LD) UTx is a challenging surgical procedure since it poses ethical issues, and it is a high-risk and invasive surgery with higher hysterectomy-related risks compared to conventional hysterectomy. A total of 59 living-donor hysterectomies have been reported in the literature, including 35 performed with a laparotomic approach, 20 with a robotic approach and 4 with a laparoscopic approach. The mean donor age was 45.6 ± 9.1 years, and 22 were unrelated with the recipients, 34 were emotionally related (27 mothers, 5 sisters, 2 mother's sisters). The mean recipient age was 28.8 ± 4.5 years. Mayer–Rokitansky–Küster–Hauser syndrome was the most common indication for uterus transplant. Robotic living-donor hysterectomy had the longest operative time but resulted in a lower blood loss and postoperative stay compared to laparotomic and laparoscopic approaches. Twenty-nine births from LD-UTx have been reported, four after robotic living-donor hysterectomy and twenty-five after a laparotomic procedure. UTx is now an effective treatment for women with UFI. While living-donor UTx in some cases may be considered an experimental procedure, it offers the extraordinary possibility to give women the opportunity to have a pregnancy. Many efforts should be made to reduce the potential risks for donors, including the use of mini-invasive techniques, and the efficacy of UTx in the recipients, giving the potential harm of immunosuppression in a recipient of a non-life-saving organ. [ABSTRACT FROM AUTHOR]

Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA—OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were −11.3 (95% confidence interval (CI), −24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and −7.0 (95% CI, −20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH. [ABSTRACT FROM AUTHOR]

To examine the association between the O blood type and bleeding tendency in patient undergoing vaginal hysterectomy. This was a retrospective cohort study including all women who had undergone vaginal hysterectomy at our institution between January 2015 and September 2020. All women underwent blood type and complete blood count testing pre- and post-operatively. The estimated intraoperative blood loss, the need for blood transfusion, pre- and postoperative hemoglobin and hematocrit measurements and surgical data were recorded for all patients. Patients with known coagulopathies or those taking antithrombotic medications were excluded from the study. Statistical analysis was performed using student t, χ2, Fischer exact, and ANOVA tests as well as a stepwise logistic regression model. The study included 106 patients (35.2 %) with O and 195 patients (64.8 %) with non-O (i.e., A, B or AB) blood types. The O blood type was significantly associated with a higher risk for moderate blood loss (defined as a pre- to postoperative Hb or HCT drop >2gr or >6 %, respectively) (p = 0.012), but not with severe (defined as a Hb or HCT drop of >3gr or >9 %, respectively) perioperative bleeding, nor with the need for blood transfusion. The O blood type was found to be significantly associated with moderate but not with severe intraoperative bleeding during and following vaginal hysterectomy. [ABSTRACT FROM AUTHOR]

• Indigo carmine is useful to detect urinary tract injuries in benign vaginal surgery. • Indigo carmine could be use alone or in combined with cystoscopy. • Intravenous use of indigo carmine is safe and cost-effective. Unrecognized ureteral and bladder injury increase morbidity and mortality in gynecologic surgery. The primary objective of this study is to analyze the efficiency of a systematic intra-venous (IV) injection of carmine indigo to detect bladder injury in gynecologic vaginal surgery for benign disease. The secondary objective is to analyze the cost and use of carmine indigo. A retrospective, monocentric study was conducted in a tertiary hospital between January 2018 and October 2021. All patients undergoing a vaginal surgery of hysterectomy for benign disease or anterior prolapse were systematically included. Patients can be systematically included by the automatic coding of surgery. After anesthesia, during the patient's installation, an intravenous injection of 5 mL of intravenous indigo carmine (Carmyne®) diluted in 100 mL of physiological serum was systematically administered by the anesthesia team. Intraoperative cystoscopy was performed only in cases of suspected associated ureteral injury. We recorded 443 vaginal hysterectomies for benign disease and 95 vaginal anterior prolapse surgeries. There were 6 (1,4%) bladder injuries during vaginal hysterectomies and 1 (1,1%) bladder injury during vaginal prolapse surgery. All bladder injuries were diagnosed intraoperatively. No ureteral injury was diagnosed in this series of patients. No complication related to IV indigo carmine injection was found. In this tertiary hospital, 1085 ampoules of carmine indigo were ordered during the same period, approximatively 270 per year. The total cost to the gynecology and obstetrics department was 19,600 euros, or about 4,900 euros per year. Half of the carmine indigo was used in vaginal surgery and half in laparotomy, caesarean section and endometriosis surgery for suspected bladder or ureteral injury. [ABSTRACT FROM AUTHOR]

• 85% of patients undergoing hysterectomy for PAS will be transfused at least 1 unit of blood. • No independent risk factors for transfusion of 1–4 units of blood was identified. • Pre-operative risk factors for blood transfusion > 10 units are: vaginal bleeding, preterm delivery < 34 weeks. Placenta Accreta Spectrum (PAS) represents a particularly morbid condition for which blood transfusion is the leading cause. Delivery by cesarean hysterectomy is recommended for the management of PAS. Massive Transfusion Protocols (MTP) in obstetrics vary in definition and implementation. Given the significant blood loss during PAS cesarean hysterectomy, this is particularly important for surgeons and blood banks. Our objective was to identify risk factors for MTP in patients with antenatally suspected PAS. We performed a case-control study over a 11-year period from 2012 to 2022 at our center for Placenta Accreta Spectrum. MTP was defined by two methods, >4 units or > 10 units of red blood cells/whole blood transfused over 24 h. Antenatal, operative and post-operative outcomes were obtained from electronic medical records of these cases. During the study time frame, 142 cases were managed by our PAS team and met all criteria. 85 % (120/142) of patients were transfused at least 1 unit of blood, 64 patients (45 %) received 0–3 units of blood, 50 patients (35 %) received 4–9 units of blood and 28 patients (19.7 %) were transfused > 10 units of blood. Pre-delivery vaginal bleeding, preterm labor and delivery < 34 weeks were independently significant in transfused patients. ROC analysis revealed an area under the curve (AUC) of 0.79 (p < 0.0001) in patients transfused > 10 units, showing predictive capability for this subgroup. We here report pre-operative risk factors for MTP in patients undergoing cesarean hysterectomy for PAS. This allows for both resource utilization and patient counseling for this morbid maternal condition. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether a previous cesarean section increases the risk of perioperative and postoperative complications during vaginal hysterectomy. Methods: A retrospective cohort study of women who had undergone a vaginal hysterectomy for benign indications between 2014 and 2019 was conducted, comparing patients with or without a previous cesarean section. Perioperative and postoperative complications during vaginal hysterectomy were assessed according to the Clavien‐Dindo classification system within 30 days of surgery. Duration of surgery, estimated blood loss, and postoperative hospitalization days were also recorded. A two‐sided P value of less than 0.05 was considered significant. Results: A total of 185 women were included, 25 (13.5%) patients had undergone a previous cesarean section (study group) and 160 (86.5%) had no history of cesarean section (comparison group). We found no significant differences in demographic and clinical characteristics as well as postoperative complications and interventions, duration of surgery, estimated blood loss, and postoperative hospitalization days (P > 0.05). However, patients who underwent two or more cesarean sections had a significantly (P = 0.01) higher rate and grade of complications during vaginal hysterectomy, compared with women with only one previous cesarean section. All women who underwent two or more cesarean sections had mild complications during vaginal hysterectomy (40% grade I and 60% grade II, P = 0.01). Conclusion: Vaginal hysterectomy is a safe procedure with few severe complications, regardless of a previous cesarean section. More than one previous cesarean section may increase the risk of minor complications during a vaginal hysterectomy. Patients who underwent a previous cesarean section could be reassured that they do not face an increased risk of complications during a vaginal hysterectomy. Synopsis: Comparative study showing similar complication rates for VH in women with and without previous CS, and higher complication rates for women with ≥2 CS. [ABSTRACT FROM AUTHOR]

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

Objective: Our objective was to perform a 5‐year cost‐effectiveness analysis of transvaginal hysteropexy (HP) via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) versus vaginal hysterectomy (VH) with apical suspension via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) for the treatment of uterine prolapse. Design: A decision analytic model assessed the cost‐effectiveness of the surgical intervention over a 5‐year horizon. Setting: This model was constructed using TreeAge® software. Population or Sample: Healthy women undergoing surgery for uterine prolapse were modeled. Methods: A Markov model was constructed to simulate the possible recurrence of prolapse. Recurrence rates, repeat surgery for surgical failures and complication rates were modeled. Base case, sensitivity analyses and probabilistic modeling were performed. Main Outcome Measures: The primary outcome was the incremental cost‐effectiveness ratio (ICER) of <$100 000 per quality‐adjusted life year (QALY). Results: Using the available prolapse recurrence rates and repeat surgery rates in the literature, both HP‐SS and HP‐US are cost‐effective at a willingness‐to‐pay (WTP) threshold of <$100 000 per QALY. The incremental cost‐effectiveness ratio (ICER) for HP‐US compared to HP‐SS is $90 738.14, while VH‐US and VH‐SS are both dominated strategies. HP‐US is the optimal cost‐effective strategy but decays exponentially with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. The cost‐effectiveness acceptability curve (CEAC) favors sacrospinous hysteropexy until reaching a WTP threshold between $90 000 and $100 000. Conclusion: Hysteropexy surgical strategies are cost‐effective transvaginal surgical approaches for uterine prolapse. Vaginal hysterectomy with apical suspension becomes more cost‐effective with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. Given the variability of prolapse recurrence rates in the literature, more comparative studies are needed to understand the cost‐effectiveness relationship between these different surgical approaches. [ABSTRACT FROM AUTHOR]

Objective: To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery. Design: Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross‐sectional study. Setting: Eight clinical sites in the US Pelvic Floor Disorders Network. Population or Sample: Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015. Methods: The MRI (rest, strain) obtained 30–42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI‐based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three‐dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position. Main outcome measures: Vaginal angulation (upper, lower and upper–lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid‐vagina) at rest. Results: Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid‐vagina (p = 0.01) at rest than women with successful surgery. Conclusions: Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors. [ABSTRACT FROM AUTHOR]

This study aimed to describe an operative technique for vaginal hysterectomy (VH) and assess the costs, perioperative, and oncological outcomes for this procedure when used in the treatment of patients with low-risk endometrial cancer (LREC). A retrospective analysis of medical records was conducted on patients who underwent VH to treat precursor and invasive endometrial lesions between April 2019 and November 2021 at a single center in São Paulo, Brazil. Thirty-four patients met the inclusion criteria. The mean patient age was 61.9 years, and the mean body mass index (BMI) was 34. Obese patients (BMI ≥ 30) accounted for 77% of the sample. Preoperative functional capacity measures were Eastern Cooperative Oncology Group (ECOG) 0–1 and ECOG-2 for 91% and 9% of the patients, respectively. The mean operative time and length of hospital stay were 109 min and 1.2 days, respectively. Four patients had a conversion of the surgical route to laparotomy. No major intraoperative complications were observed. Patients who underwent surgical conversion had a greater uterine volume (227 versus 107 mL, p = 0.006) and longer operative time (177 versus 96 min, p = 0.001). The total cost associated with VH was, on average, US$ 2058.77 (R$ 10,925.91), representing 47% of the cost associated with non-vaginal routes. Twenty-eight patients received a definitive diagnosis of endometrial carcinoma; of these, three received adjuvant radiotherapy. The mean follow-up period was 34.6 months for the patients diagnosed with cancer. One case of disease recurrence occurred 16.6 months after surgery, with one death at 28.6 months of follow-up. These findings suggest that VH could be a feasible and cost-effective alternative for selected patients with LREC in low-resource settings. • The study describes a reproducible and oncologically safe technique for treating endometrial cancer via the vaginal route. • The largest series of endometrial cancer cases treated via the vaginal route in Brazil is also presented. • Safety criteria should be respected when performing vaginal hysterectomy for patients with endometrial cancer. • Vaginal hysterectomy appears to be cost-effective for the treatment of patients with low-risk endometrial cancer. • The vaginal route may serve as an alternative point of access for the treatment of patients in low-resource settings. [ABSTRACT FROM AUTHOR]

Objective: This study assessed postoperative complication rates for hysterectomy routes years after the U.S. Food and Drug Administration (FDA) statement warning against power morcellators use. Materials and Methods: The American College of Surgeons National Surgical Quality Improvement Program® database was used to evaluate hysterectomies performed prestatement (2009–2013) and poststatement (2015–2019). Primary outcomes were 30-day postoperative complication which were categorized as overall, major and minor complications. A secondary outcome was route of hysterectomy. A subanalysis was performed for fibroid hysterectomies. Results: Prestatement versus poststatement complication rates, respectively, were as follows. In 309,783 hysterectomies for benign indications, overall: 9.4% versus 8.9% (adjusted odds ratio [aOR]: 0.92; 95% confidence interval [CI]: 0.89, 0.94]); major: 3.5% versus 3.3% (aOR: 0.95: 95% CI: 0.90, 0.99); and minor: 6.9% versus 6.4% (aOR: 0.89; 95% CI: 0.86, 0.92) complication rates were significantly lower in the poststatement period. There was an increase in laparoscopic (51.4% versus 59.3%) and decreases in open (27.0% versus 21.7%) and vaginal (21.7% versus 19.0%) approaches. In 96,985 hysterectomies for fibroids, complication rates were unchanged with overall: 9.4% versus 9.5% (aOR: 0.97; 95% CI:, 0.92, 1.03); major: 3.1% versus 3.2% (aOR: 0.98; 95% CI: 0.89, 1.07); and minor: 7.1% versus 7.2% (aOR: 0.98; 95% CI: 0.92, 1.04) complications, with a similar increase in laparoscopic (50.9% versus 55.5%) and a decrease in open (41.5% versus 37.7%) and vaginal (7.7% versus 6.8%) approaches. Conclusions: Years after the FDA statement, postoperative complication rates have decreased for benign hysterectomies and remain unchanged for fibroid hysterectomies with rising rates of laparoscopic hysterectomies. While there may have been an increase in complications and open surgeries after the statement, these trends were transient and have reversed. (J GYNECOL SURG 40:32) [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair. METHODS: This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosac-ral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with PC.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model. RESULTS: One hundred eighty-six participants underwent surgery;183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.860.98, P=.016). CONCLUSION: Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair. [ABSTRACT FROM AUTHOR]

Objective: The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment. Method: In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure's efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality. Results: Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required >3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine. Conclusion: SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum. [ABSTRACT FROM AUTHOR]

Objective: To report the results of prophylactic use of intraoperative temporary internal iliac arterial occlusion by Bulldog clamps in patients clinically diagnosed with abnormally invasive placenta. Methods: This retrospective study included 61 patients diagnosed with FIGO grade 3 abnormally invasive placenta between January 2018 and March 2022. After transfundal incision and fetal delivery, bilateral temporary internal iliac arterial occlusion by Bulldog clamps was performed in all patients. The grades 3b and 3c group underwent cesarean hysterectomy whereas selected cases of grade 3a abnormally invasive placenta underwent fertility‐preserving procedures. Preoperative and postoperative findings were compared. Results: Cesarean hysterectomy was performed in 50 (82%) patients and cesarean plus conservative procedures were performed in 11 (18%) patients. Intraoperative blood replacement was not performed in 83.6% of all patients. Mean blood loss was 1.37 ± 0.53 L (range 0.5–2.5) in all patients. Estimated blood loss was significantly higher in cesarean hysterectomy group. There was no statistically significant difference between two groups in terms of peroperative blood replacement, bladder, and ureteral injury. Conclusion: Prophylactic bilateral temporary internal iliac arterial occlusion by Bulldog clamps should be performed in cases of grade 3 abnormally invasive placenta. Fertility‐preserving steps may be undertaken safely in selected cases with this approach. Synopsis: Prophylactic temporary internal iliac arterial occlusion by Bulldog clamps should be considered in abnormally invasive placenta. Acceptable estimated blood loss is observed with this technique. [ABSTRACT FROM AUTHOR]

Background: One of the most commonly performed gynaecological procedure worldwide is hysterectomy. Important indication for hysterectomy is abnormal uterine bleeding. Due to common use, there has been a need to standardize causes of abnormal uterine bleeding. To fulfil the need PALM-COEIN classification has been recommended that incorporates structural and non-structural causes contributing to abnormal uterine bleeding. The objective of this study was to examine the indications for hysterectomies performed in a tertiary care hospital, using the PALM-COEIN classification Materials & Methods: It was a retrospective observational study, carried out in Lady Reading Hospital Peshawar. Data was collected over 5 years (from 2016-2022 with two years (2020 and 2021) of Covid surge excluded). Data was collected, on specially designed proformas for all cases undergoing total abdominal hysterectomies for abnormal uterine bleeding. Obstetric and vaginal hysterectomies as well as those done for reasons other than uterine bleeding i.e large fibroids and ovarian malignancies were excluded from the study. Demographic data was noted and indications were grouped according to PALM COEIN classification and compared over the mentioned years. Data was entered and analysed using SPSS v23. Continuous variables were reported as mean and standard deviation and categorical variables as frequencies and percentages. Results: A total of 854 cases were collected over the 5 years, with 634 hysterectomies happening from 2016 till 2019 for AUB. Mean age of study sample was 48.5 years ± 1.7. Forty Six patients (5.3%) of the total 854 cases were due to polyps (predominantly endometrial). Two hundred and twenty one cases (25.8%) were having adenomyosis. Fibroids were the most frequently detected finding, occurring in 293 (34.3%) of cases. Malignancies accounted for 54 (6.3%) of cases. Ovulatory disorders accounted for 11 (1.2%) of cases. One hundred and fifty five (18%) cases had endometrial cause. About 8.6% (n=74) of cases had no identifiable specific cause. Conclusion: Our study demonstrates that PALM COEIN classification system can provide a suitable tool to classify women presenting with AUB. [ABSTRACT FROM AUTHOR]

Purpose: Pelvic organ prolapse (POP) surgery is performed with and without concomitant hysterectomy depending on a variety of factors. The objective was to compare 30-day major complications following POP surgery with and without concomitant hysterectomy. Methods: This was a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) multicenter database to compare 30-day complications using Current Procedural Terminology (CPT) codes for POP with or without concomitant hysterectomy. Patients were grouped by procedure: Vaginal prolapse repair (VAGINAL), minimally invasive sacrocolpopexy (MISC), and open abdominal sacrocolpopexy (OASC). 30-day postoperative complications and other relevant data were evaluated in patients who underwent concomitant hysterectomy compared to those who did not. Multivariable logistic regression models assessed the association of concomitant hysterectomy on 30-day major complications stratified by surgical approach. Results: 60,201 women undergoing POP surgery comprised our cohort. Within 30 days of surgery, there were 1722 major complications in 1432 patients (2.4%). Prolapse surgery alone had a significantly lower overall complication rate than with concomitant hysterectomy (1.95% vs 2.81%; p <.001). Multivariable analysis revealed odds of complications following POP surgery was higher among women who underwent concomitant hysterectomy compared to those who did not have hysterectomy in VAGINAL (OR 1.53, 95% CI 1.36–1.72), OASC (OR 2.70, 95% CI 1.69–4.33), and overall (OR 1.46, 95% CI 1.31–1.62), but not in MISC (OR 0.99, 95% CI 0.67–1.46.) Conclusion: Concomitant hysterectomy at the time of pelvic organ prolapse (POP) surgery increases the risk of 30-day postoperative complications in comparison to prolapse surgery alone in our overall cohort. [ABSTRACT FROM AUTHOR]

Background: Hysterectomy is the commonest major surgical procedure performed in gynaecology. It is important to conduct audit on hysterectomy to bring down rate of hysterectomies and to avoid unnecessary hysterectomies. Methods: It is a retrospective study. A total of 437 cases who underwent hysterectomy were studied over a period of 1year from January 1st 2022 to December 31st 2022. Objective: To evaluate the indications of hysterectomy and histopathological analysis of hysterectomy specimens for confirmation of preoperative diagnosis and to assess the pattern of lesions common in uterus and adnexae in the study population. Results: A total of 437 cases were studied. The peak age group of hysterectomy was 41-50 years with 225(51.49%) cases. The most common indication was fibroid uterus (289, 66.13%). The commonest route of hysterectomy was abdominal (370,84.67%). The most common endometrial finding was proliferative endometrium seen in 199(45.54%) cases. The most common pathology in myometrium was leiomyoma seen in 270(61.78%) cases. The most common pathology in cervix was chronic cervicitis seen 245(56.06%) cases. Conclusion: There is a need for shifting the route of hysterectomy from abdomen to vaginal route as complication rate is low in Vaginal route. Educating the patient regarding the non-surgical and less invasive management options available for benign conditions and about the sequele of hysterectomy to bring down the rate of hysterectomy. [ABSTRACT FROM AUTHOR]

Paraganglioma is a rare neuroendocrine tumour that involves neural structures and blood vessels and occurs due to abnormal migration of neural crest cells. These tumours secrete catecholamines, posing a significant threat to patients. Here we describe a case of a 48-year old female who came with a big abdominopelvic mass and prolapsed uterus. Following routine lab analysis and contrast-enhanced computed tomography (CECT) imaging, she underwent exploratory laparotomy, where the abdominal mass was excised, and sigmoid colectomy and covering ileostomy followed by vaginal hysterectomy. Her post-operative histo-pathology report revealed the rare diagnosis of paraganglioma, characterised by positive markers for chromogranin (diffuse), CD56 (diffuse), INSM1 (focal, weak to moderate), and GATA3 (focal, weak to moderate) while negative for S-100 and PanCK. DOTA-PET was done which did not show any residual disease. After a multi-disciplinary tumour board meeting, it was decided to keep her under observation. Diagnosis of such rare endocrine neoplasms is not to be missed and it is important to bring such cases to the purview of the clinicians for improved understanding and management. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Women with central sensitisation syndrome (CSS) experience poorer subjective post-operative outcomes even after successful pelvic floor reconstruction. This study tests the hypothesis that women with pelvic floor symptoms (PFS) without relevant pelvic organ prolapse (POP), are more likely to have CSS. Methods: A questionnaire was sent to women who participated in the POP-UP study in 2017. The POP-UP study evaluated POP in 247 women 16 years after laparoscopic or vaginal hysterectomy. POP-Q data and Pelvic Floor Distress Inventory (PFDI-20) results were used and supplemented with CSS-specific questionnaires. A Central Sensitisation Inventory (CSI) score above 40 implicates CSS. Women were divided into groups based on POP beyond the hymen in relation to the PFDI-20 score. Outcomes of women with PFS and without POP (called 'group 1') were compared with the rest of the cohort (groups 2–4; women without PFS and/or with POP). Results: A total of 136 women were included in the analysis. A CSI score above 40 was present in 16 out of 42 women of group 1 (37%) versus 11 out of 93 women of groups 2–4 (12%), p < 0.0001. Passive coping was more prevalent in group 1 (p = 0.039), and more deviations in somatisation, depression, anxiety and distress were found in group 1 (p values of < 0.0001, 0.018, 0.003 and 0.002 respectively). Conclusions: This study suggests that CSS might be more prevalent in women with PFS without relevant POP. More awareness of CSS and valid individual counselling may overcome unnecessary surgery for POP and help in setting realistic expectations. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Post-hysterectomy vault prolapse poses significant challenges to patients and surgeons alike. Despite numerous surgical interventions during initial vaginal hysterectomy to counteract this, a comparative analysis of their efficacy is limited. This study introduces a pioneering technique intended to avert vault prolapse during vaginal hysterectomy by harmoniously merging level 1 and level 2 support. Methods: After obtaining informed consent, we recorded a variation of the McCall technique performed during vaginal hysterectomy and anterior repair. Patient follow-ups were conducted up to 6 months post-operation to evaluate anatomical outcomes and quality of life. Results: A total of 46 women underwent the surgery. Anatomical evaluations at the 6-month mark were commendable, with no recurrence instances. Quality-of-life assessments, using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12), showcased substantial improvement. Conclusion: Our novel approach to vault suspension provides an uncomplicated, easily impartible, surgical procedure utilizing standard sutures. We believe that this approach is both enduring and safe. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The objective was to evaluate the efficacy of pessaries in the treatment of stage IV pelvic organ prolapse (POP) and identify the influencing factors. Methods: One hundred and fifty-seven patients with stage IV symptomatic POP were admitted to the hospital for pessary fitting. A successful pessary fitting was defined as a patient fitted with a pessary at the initial fitting in whom use continued 2 weeks later. The rates of successful pessary fitting, patient satisfaction, remission of prolapse and urinary symptoms, and the occurrence of factors associated with successful pessary fitting were calculated and predictors of appropriate pessary type selection were analyzed. Results: A total of 130 patients with stage IV POP had a successful pessary fitting (82.8%). The satisfaction rate associated with the two types of pessaries was more than 90%. The success rate among patients undergoing a ring pessary fitting trial was 44.6%, and 84.3% of the patients were self-managed. Prolapse symptoms significantly improved in 90% of cases, and urinary symptoms improved in 58–93% of cases from baseline. The number of vaginal deliveries, history of hysterectomy and vaginal introitus/total vaginal length (TVL) ratio were independent risk factors associated with unsuccessful pessary fitting. Conclusion: For patients with stage IV POP, the successful fitting rate is as high as 80% or more. More vaginal deliveries, a history of hysterectomy, and a larger vaginal introitus/TVL ratio (ratio >0.6) were predictors of unsuccessful pessary fitting. [ABSTRACT FROM AUTHOR]