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Purpose: The purpose of this study was to perform a meta-analysis comparing the short-term and long-term outcomes in laparoscopic groin hernia repair with or without preservation of the uterine round ligament (URL) in females., Methods: We searched several databases including PubMed, Web of Science, Cochrane Library, and and CNKI databases. This meta-analysis included randomized clinical trials, and retrospective comparative studies regarding preservation or division of the URL in laparoscopic groin hernia repair in females. Outcomes of interest were age, BMI, type of hernia, type of surgery, operating time, estimated blood loss, time of hospitalization, seroma, concomitant injury, mesh infection, recurrence, uterine prolapse, foreign body sensation, chronic pain, and pregnancy. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively., Results: Of 192 potentially eligible articles, 9 studies with 1104 participants met the eligibility criteria and were included in the meta-analysis. There were no significant difference in age (MD-6.58, 95% CI - 13.41 to 0.24; P = 0.06), BMI (MD 0.05, 95%CI - 0.31 to 0.40; P = 0.81), blood loss (MD-0.04, 95% CI - 0.75 to 0.66; P = 0.90), time of hospitalization (MD-0.22, 95% CI-1.13 to 0.69; P = 0.64), seroma (OR 0.71, 95% CI 0.41 to 1.24; P = 0.23), concomitant injury (OR 0.32, 95% CI 0.01 to 8.24; P = 0.68), mesh infection (OR 0.13, 95% CI 0.01 to 2.61; P = 0.18), recurrence (OR 1.13, 95% CI 0.18 to 7.25; P = 0.90), uterine prolapse(OR 0.71, 95% CI 0.07 to 6.94; P = 0.77), foreign body sensation (OR 1.95, 95% CI 0.53 to 7.23; P = 0.32) and chronic pain(OR 1.03 95% CI 0.4 to 2.69; P = 0.95). However, this meta-analysis demonstrated a statistically significant difference in operating time (MD 6.62, 95% CI 2.20 to 11.04; P = 0.0003) between the preservation group and division group. Trial sequential analysis showed that the cumulative Z value of the operating time crossed the traditional boundary value and the TSA boundary value in the third study, and the cumulative sample size had reached the required information size (RIS), indicating that the current conclusion was stable., Conclusion: In summary, laparoscopic groin hernia repair in women with the preservation of the round uterine ligament requires a longer operating time, but there was no advantage in short-term or long-term complications, and there was no clear evidence on whether it causes infertility and uterine prolapse., (© 2024. The Author(s).)

Round ligament endometriosis is a rare phenomenon reported in approximately 0.3% to 0.6% of endometriosis cases. Presurgical diagnosis is carried out for about 50% of the cases. The association of the right-sided inguinal hernia, nonspecific pain in the organs, and no history of surgery or labor make the diagnosis intricate. We report a case of endometriosis of the round ligament in a 39-year-old woman who complained of intense pain in the right groin during the menstrual period for about 4 years, with no complaints of bulging or change in the size of the mentioned area. The clinical suspicion of inguinal endometriosis, supported by sonography and magnetic resonance imaging, was confirmed by histological examination of the surgical specimen after laparoscopic surgery, which included the mass and the extraperitoneal segment of the round ligament. After surgery, the patient's pain disappeared completely. The round ligament endometriosis or endometriosis of the inguinal region could be considered an important differential diagnosis in women of reproductive age without a history of surgery who presented with inguinal region pain during menstruation but no clear mass was palpable in the physical exam.

We report two cases of endometriosis of the round ligament in a 37 and 26 - years old women, with a lump in their right groin and catamenial pain referred to plastic surgery department. MRI showed in both cases nodular lesion in the right inguinal region. The patological examination of the surgical specimen revealed endometriosis of the round ligament. The presence of a groin mass with pain increasing during the menstrual period must raise the suspicion of inguinal endometriosis and a gynecological evaluation is essential to provide a correct management of this rare condition.

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier B.V.)

Background: Inguinal endometriosis (IEM) is a rare extra pelvic endometriosis. Here, we study the clinical characteristics, management strategies, and long-term gynecological outcomes of IEM patients at Beijing Chaoyang Hospital., Case Presentation: Three patients presented with a total of four lesions (one on the left side, one on the right side, and one bilaterally). The diameters of the four lesions were 2 cm, 2 cm, 3.5 cm and 1.5 cm, respectively. Two patients were admitted with inguinal hernias. Two patients were admitted with endometrioses-one with ovarian endometriosis and one with pelvic endometriosis. The hernia sac was repaired concomitantly via excision of the round ligament in two patients. One patient underwent a concomitant laparoscopy for gynecologic evaluations, including an ablation to the peritoneal endometriosis, and resection of the left uterosacral ligament endometriosis and pelvic adhesiolysis. All lesions were located on the extraperitoneal portion of the round ligament and were diagnosed histologically. No recurrence was observed in the inguinal region. All patients diagnosed with adenomyosis were treated with medication alone without any complaints., Conclusions: Inguinal endometriosis can occur simultaneously with pelvic endometriosis. In most cases, a concomitant hernia sac appears together with groin endometriosis. Clinical management should be individualized and performed in tandem with general practitioners and obstetrics & gynecology experts. Pelvic disease, in particular, should be followed-up by a gynecologist.

Background: Laparoscopic repair has been recommended as the method-of-choice of groin hernia repair among women. Whether the round ligament of uterus should be divided to facilitate mesh placement remains controversial. This study aims to review the outcomes of laparoscopic total extraperitoneal (TEP) groin hernia repair in women and to evaluate the impact of division of round ligament. Methods: Consecutive female patients with inguinal or femoral hernias who underwent elective laparoscopic TEP repair at a single institution from 2006 to 2017 were included for retrospective analysis. Primary outcomes were postoperative pain, genital prolapse, and recurrence. Outcomes of patients who had the round ligament divided were further compared with those with round ligament preserved and multivariable adjusted analysis was performed. Results: Sixty-eight patients with a total of 77 TEP repairs were included in the 12-year study period. The mean age was 45 ± 16 years old. Incidental femoral hernia was identified in 4 patients (5.9%). There was 1 (1.3%) recurrence upon mean follow-up of 42.9 ± 37.3 months. The round ligament was divided in 67.5% of patients, and upon multivariable adjusted analysis, there were no statistically significant differences in outcomes in terms of chronic pain (odds ratio [OR] = 2.210, P  = .357), paresthesia (OR = 0.241, P  = .149), and genital prolapse (OR = 0.327, P  = .415) when compared with patients with preserved round ligament. Conclusion: Laparoscopic groin hernia repair in women is associated with low recurrence. Division of round ligament intraoperatively facilitates mesh placement and has minimal impact on clinical outcomes.

Study Objective: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes., Design: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ 2 test and the Fisher exact test. A p-value <.05 was considered significant., Setting: Teaching hospital., Patients: Forty patients who underwent TULH from 2009 to 2017., Interventions: TULH., Measurements and Main Results: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP., Conclusion: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Differential diagnosis of inguinal mass must include, especially in female patients, a wide variety of lesions among which our analysis will focus on mesothelial cyst of the round ligament of the uterus. A rare developmental lesion often misdiagnosed as hernias and accidentally detected during surgical exploration of the groin region., Case Report: Of a left inguinal mass causing local discomfort and progressive worsening of local pain. A pre-operative diagnosis of left symptomatic femoral hernia was made and the patient consented to surgical treatment. The surgical exploration of the inguinal and femoral canals revealed a femoral hernia associated to a clear fluid cystic lesion of around 2 cm arising from the round ligament. Histopathology demonstrated a mesothelial cyst of the round ligament CONCLUSIONS: Mesothelial cysts of the round ligament of the uterus must be taken into consideration in the differential diagnosis of groin swelling in female patients and a greater effort is needed in order to reach a preoperative diagnosis and prevent an over treatment. Key words: Mesothelial cyst, Preoperative diagnosis, Uterus.

Aim: Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy., Methods: This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations., Results: LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007)., Conclusion: LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected., (© 2019 Japan Society of Obstetrics and Gynecology.)

A gravida 4 para 1021, 41-year-old woman postcaesarean section at 39 weeks and 1 day with clinically significant haemorrhage required embolisation of unique uterine arterial collaterals. She had persistent haemorrhage after initial bilateral uterine artery embolisation, and on further investigation she was found to have a hypertrophied right round ligament artery. Once successful embolisation of this abnormal right round ligament artery was completed using a combination of Gelfoam and coils, haemostasis was achieved. She had rapid clinical improvement, no complications and no further admissions on postprocedural follow-up over a year and a half later., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the indications and clinic outcomes of vaginal high uterosacral ligament suspension (HUS) for treatment of recurrent advanced pelvic organ prolapse (POP). Methods: This retrospective study analyzed 42 women with recurrent advanced POP who were referred to Fourth Medical Center of PLA General Hospital and underwent transvaginal HUS between November 2005 and January 2018. Primary surgeries included 30 vaginal colporrhaphy, 5 Manchester operation, 5 transvaginal mesh repair,2 sacrospinous ligament fixation.The median time for recurrence from primary pelvic floor repair surgery was 9 months, including 14 cases (33%, 14/42) ≤3 months (median time was 2 months) and 25 cases (67%, 28/42) longer than 3 months (median time was 18 months).The rate of recurrent prolapse in stage Ⅲ or Ⅳ was 79% (33 cases), 45% (19 cases) and 17%(7 cases) in anterior, apical and posterior compartment respectively. Results: Transvaginal high bilateral uterosacral ligaments were identified and used for successful vaginal vault suspension after vaginal hysterectomy and residual cervical resection in all 42 consecutive patients. The cases of transvaginal mesh used in anterior wall and posterior wall were 25 (60%, 25/42) and 3 (7%, 3/42) respectively. There was no major intra- and postoperative complications,such as ureter and other pelvic organ injury. The median time of follow-up was 5.3 years after transvaginal HUS. The points of pelvic organ prolapse quantification system reduced significantly and point C improved from +0.3 cm to -8.2 cm after reoperation ( P< 0.01). The objective cure rate were 100% (42/42) both in apex and posterior compartment,while 93% (39/42) in anterior compartment. None had reoperation or pessary usage for recurrence of prolapse. Conclusion: Transvaginal HUS with vaginal wall repair could be as a safety, cost-effective, minimal traumatic and durable procedure for recurrent POP in the most of cases.

Background: Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed., Methods: The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%., Discussion: This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed., Trial Registration: Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.

Hysterectomy is a potential risk factor for subsequent surgery for pelvic organ prolapse, especially when the prolapse exists before hysterectomy. Women without prolapse before hysterectomy may also experience prolapse after hysterectomy. This study aimed to describe a surgical modification of laparoscopic colposuspension with round ligaments after hysterectomy in women without preexisting genital prolapse and to evaluate the initial surgical results in these patients.We reviewed data of 54 patients who underwent laparoscopic hysterectomy with colposuspension with unilateral or bilateral round ligaments after hysterectomy at Chia-Yi Chang Gung Memorial Hospital from July 2012 to March 2015. Vaginal length was measured before and after colposuspension after complete hysterectomy. Preoperative characteristics of the patients, perioperative quality, postoperative outcomes, and vaginal length differences were analyzed.Vaginal length increased by a mean of 2.59 cm after colposuspension. The mean extra-operative time needed for laparoscopic colposuspension was about 10 minutes. No severe complications were reported in our patients, and we did not find any cystocele after completing vaginal cuff suspension to the round ligament.The vaginal apex level was maintained in our modified laparoscopic hysterectomy. Therefore, laparoscopic colposuspension with round ligaments is a promising option as a routine, first-line standard procedure in younger women without genital prolapse to maintain an acceptable vaginal length after laparoscopic hysterectomy.

Background: Our objective was to investigate the clinical characteristics of laparoscopic repair for groin hernias in female patients., Study Design: The clinical data of 316 female patients (341 hernias) who underwent laparoscopic inguinal hernia repair at Shanghai Minimally Invasive Surgery Center between January 2001 and December 2015 was analyzed retrospectively. The operation-related data were to provide an overview of female groin hernias, preferred surgical approach, and the management of round ligament of uterus., Results: There were 274 transabdominal preperitoneal patch plastic repairs and 67 total extraperitoneal repairs performed on 257 and 59 patients, respectively. The median follow-up period was 48 months. Fifty-eight femoral hernias were noted in 52 patients, of which 18 femoral hernias were incarcerated. Cysts on the round ligament of uterus were found in 39 patients, and most of them underwent laparoscopic resection. Round ligaments of uterus were preserved in 152 patients and transected in 162 patients. The preservation group requires longer operation time and trickier surgical technique. None of the cases was converted to laparotomy. All patients returned to normal activity soon and no recurrence was noted during follow-up., Conclusions: Laparoscopic inguinal hernia repair is well adopted around the world. Meanwhile, there still remain questions to be discussed in female patients. Based on this study, the round ligament cyst could be resected while the operation. Either "open and suture" or keyhole technique will be available to preserve the round ligament of uterus.

Mesothelial cyst of the round ligament is a rare finding in females, with only a few cases reported so far. A case of a 25 year old female patient presenting with a palpable mass in her right inguinal region is presented. The preoperative investigation through ultrasound (U/S), computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an intraabdominal cystic lobular mass in the inguinal canal, in contact with the femoral vessels. The mass was excised and the diagnosis of a benign mesothelial cyst was made through pathological examination. Even though it is a rare condition, it is advisable that clinicians consider in the differential diagnosis when evaluating a non-reducible mass in the inguinal region of a female patient.

A 14-year-old female patient consulted due to 4 months of recurrent right pelvic pain during her menstrual period. Sonography revealed a 35 mm haemorrhagic right ovarian cyst, initially treated with hormone therapy and oral analgesics with no response. Surgery was indicated due to growth on sonography control and no response to medical treatment. Laparoscopy showed a 7 cm leiomyomatous-like mass arising from the right round ligament that was extracted en bloc without rupture with right salpingectomy and ovarian preservation. The histopathological examination confirmed the diagnosis of round ligament endometrioma with no atypia. The patient presented an uncomplicated postoperative course and was discharged home 48 hours after surgery. Hormonal contraceptives were initiated after the histopathological confirmation; the patient remains asymptomatic at 1-year follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Round ligament mesothelial cyst is a rare cause of inguinal mass. Round ligament cysts are generally diagnosed during operation in cases who are operated with a pre-diagnosis of inguinal hernia. In this study, we aim to present two cases, who have applied to our clinic with the complaint of a mass in inguinal region and who are diagnosed as round ligament cyst, together with their ultrasound, magnetic resonance images and operation images.

Objective: Primary tumors of round ligament are rare, and when found are typically leiomyomas. Endometrioma, and mesothelial cysts are the benign lesions recognized as involving the round ligament. We report a case of lipoma of the round ligament in a 48-year-old premenopausal woman. Round ligament lipoma on the intraperitoneal portion (abdominal site) is very rare and it should be kept in the differential diagnosis of ovarian and abdominal masses.

Study Objective: To show a new laparoscopic technique of hysteropexy for uterine retrodisplacement (retroversion and/or retroflexion)., Design: Narrated step-by-step explanation of the Bologna hysteropexy technique using descriptive text and an educational video., Setting: Tertiary referred center of minimally invasive gynecology, Sant'Orsola Hospital, Bologna University., Interventions: The Bologna hysteropexy is proposed as an additional procedure after surgical laparoscopic interventions for benign gynecologic disease. The technique consists of 2 semicontinuous absorbable sutures (Biosyn monofilament no. 1 [Covidien, Mansfield, MA] with 2/3 inch diameter needle, 36 mm) suspending the uterus to the anterior abdominal wall, through the plication and shortening of round ligaments. A knot is tied intracorporeally between the 2 free ends of the semicontinuous sutures, drawing a V shape figure and resulting in uterine ventrosuspension., Conclusion: The Bologna technique hysteropexy is simple and quick to perform. It is effective in suspending the uterus in anteverted and anteflexed positions at 6-month ultrasound follow-up. No perioperative complications were recorded. It can be done with a standard surgical suture-passer and does not add additional cost to surgery. Furthermore, an absorbable suture is desirable for fertile women., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: Studies on pelvic organ prolapse (POP) surgery show conflicting evidence regarding the impact of uterus preservation and hysterectomy on sexual function and no large randomized trials with long-term follow-up have been published on this topic., Aims: The aim of this secondary analysis was to evaluate and compare sexual function after sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse., Methods: This is a secondary analysis of the SAVE U trial data, a multicenter trial in 4 nonuniversity hospitals in the Netherlands comparing sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments in primary surgery of uterine prolapse stage II or higher. Primary outcome of the original study was recurrent prolapse stage II or higher of the uterus or vaginal vault (apical compartment) evaluated by POP-Q examination in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months follow-up. Secondary outcomes were overall anatomical recurrences, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning. Data from patients who had completed the POP/urinary incontinence sexual questionnaire (PISQ-12) at baseline and 24 months after surgery were used in the present trial. Total, subscale, and individual question analyses were performed. The SAVE U trial is registered in the Dutch trial registry, number NTR1866., Main Outcome Measures: Differences and changes in sexual function 24 months after surgery, measured by the PISQ-12 questionnaire., Results: Between November 2009 and March 2012, 208 women were randomized between sacrospinous hysteropexy (n = 103) and vaginal hysterectomy with suspension of the uterosacral ligaments (n = 105). Of these, 99 women completed questionnaires at baseline and after 24 months follow-up and were included in the present study. During a follow-up period of 24 months, no significant differences in total PISQ-12 scores were observed between the groups. After both interventions the item "avoidance of intercourse due to prolapse" significantly improved, as did the physical subscale of the PISQ-12 questionnaire., Conclusion: There was no statistically significant difference in overall sexual functioning (total PISQ-12 scores) between uterus-preserving sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments after a follow-up period of 24 months., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Patients with congenital genitourinary abnormalities are growing into adulthood and their expectations, especially in the areas of sexual function and fertility are creating unforeseen challenges for health care providers. We review the incidence and management of pelvic organ prolapse at our Transitional Urology Clinic., Materials and Methods: This study is a retrospective chart review of the presentation and treatment of patients with clinically bothersome pelvic organ prolapse seen at our tertiary Transitional Urology Clinic during 2012 to 2015., Results: Seven patients with a mean age of 22.8 years presented to our clinic with clinically bothersome prolapse. Four patients had myelomeningocele, 2 had sacral agenesis and 1 had bladder exstrophy. All were on self-catheterization. Three patients were sexually active and 1 had an intact uterus and desired fertility. Bothersome symptoms included vaginal bulge in 6 cases, difficult vaginal intercourse in 1 and difficult catheterization in 1. For the leading edge of Bp (anterior compartment) prolapse the median POP-Q (Pelvic Organ Prolapse Quantification System) stage was 3 (range 1 to 3), for Bp (posterior compartment) prolapse it was 1 (range 0 to 3) and for C (vaginal vault or cervical) prolapse it was 2 (range 1 to 3). Management included pessary in 1 case, hysterectomy with bilateral uterosacral ligament suspension in 4, sacrocolpopexy in 1 and observation in 1. Mean followup was 17.6 months (range 1 to 92). One of the 5 patients treated with surgical intervention had recurrence in the anterior compartment and vaginal vault., Conclusions: Females with congenital genitourinary anomalies present with pelvic organ prolapse at a much younger age and a more advanced stage. There is a paucity of literature on the epidemiology, presentation and management of pelvic organ prolapse in this patient population., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

We describe a rare case of a young woman with a large cystic adenomyotic lesion that was treated laparoscopically. The patient presented with severe dysmenorrhoea refractory to common analgaesics. She was initially diagnosed with right-sided ovarian endometrioma. MRI revealed a cystic lesion of 4 cm attached to the right uterine wall. Under laparoscopic vision, the uterine lesion was identified on the right portion of the uterine fundus close to the round ligament. Monopolar diathermy was used to dissect the lesion. When the incision reached the cystic cavity, dark-brown content flowed from the cyst. After resection was complete, the surgical wound was closed with two-layer interrupted sutures. The patient made a good recovery and was discharged the following day. Since patients with cystic adenomyosis are young, a minimally invasive procedure such as laparoscopic excision is considered optimal. The exact topography of the lesion is crucial in determining the site of the incision., (2015 BMJ Publishing Group Ltd.)

Prophylactic salpingectomy at the time of hysterectomy has been recommended for women at average risk for ovarian cancer. Vaginal hysterectomy is considered the preferred approach to a benign hysterectomy, and adnexectomy should not be considered a contraindication to this approach. This paper with accompanying video describes and demonstrates the round ligament technique and use of a vessel-sealing device to facilitate removal of the entire fallopian tube at the time of vaginal hysterectomy., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate whether uterus preserving vaginal sacrospinous hysteropexy is non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments in the surgical treatment of uterine prolapse., Design: Multicentre randomised controlled non-blinded non-inferiority trial., Setting: 4 non-university teaching hospitals, the Netherlands., Participants: 208 healthy women with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery., Interventions: Treatment with sacrospinous hysteropexy or vaginal hysterectomy with suspension of the uterosacral ligaments. The predefined non-inferiority margin was an increase in surgical failure rate of 7%., Main Outcome Measures: Primary outcome was recurrent prolapse stage 2 or higher of the uterus or vaginal vault (apical compartment) evaluated by the pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months' follow-up. Secondary outcomes were overall anatomical recurrences, including recurrent anterior compartment (bladder) and/or posterior compartment (bowel) prolapse, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning., Results: Sacrospinous hysteropexy was non-inferior for anatomical recurrence of the apical compartment with bothersome bulge symptoms or repeat surgery (n=0, 0%) compared with vaginal hysterectomy with suspension of the uterosacral ligaments (n=4, 4.0%, difference -3.9%, 95% confidence interval for difference -8.6% to 0.7%). At 12 months, overall anatomical recurrences, functional outcome, quality of life, complications, hospital stay, measures on postoperative recovery, and sexual functioning did not differ between the two groups. Five serious adverse events were reported during hospital stay. None was considered to be related to the type of surgery., Conclusions: Uterus preservation by sacrospinous hysteropexy was non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for surgical failure of the apical compartment at 12 months' follow-up., Trial Registration: trialregister.nl NTR1866., (© Detollenaere et al 2015.)

A swelling in the groin is a highly prevalent complaint. However, surgical exploration can sometimes reveal an unexpected finding, such as in our case of a postmenopausal 52-year-old female patient. After surgical excision, a left groin mass appeared to be a leiomyoma of the round ligament of the uterus.

A 40-year-old Caucasian female patient presented to the outpatient General Surgery ward in "V. I. Lenin" Teaching Hospital complaining of a recurrent mesogastric pain that had lasted for 3 months. Physical examination showed a palpable mass confined to that area. She was then admitted with diagnosis of an abdominal tumour. Diagnostic work-up revealed that the process involved the round ligament of the liver, which is an exceptional localization, which motivated us to publish this case after surgical treatment by excision, having also taken into account the results of histopathology which revealed a PEComa, confirmed by inmunohistochemistry. After reviewing the available literature, the low incidence of these lesions, as well as the unusual histological variety, makes the present case one of interest.

Fertility sparing surgery might be a benefit for young patients with early-stage cervical cancer. The authors herein describe a case of adenocarcinoma of cervix Stage IA2 treated with laparoscopic radical trachelectomy (LRT) with round ligament and uterine artery preservation.

An exhaustive search of the literature using the Pub Med database revealed no reports of round ligament lipomas mimicking acute appendicitis in pregnant patients. There are relatively few articles on round ligament lipomas and even less on round ligament lipomas during pregnancy. This case report is on a 27-year-old 24-week pregnant female who presented with signs and symptoms similar to acute appendicitis who in fact had a large right pelvic round ligament lipoma that was causing her pain.

We report on a 49-year-old woman with cysts of the round ligament causing a nonreducible mass of the groin. Cysts of the round ligament are rare. Physical findings were similar to those of an inguinal hernia. Such cysts are usually not considered in the differential diagnosis of groin hernias and might be identified only at the time of herniorraphy.

For the past 15 years gynecological oncologists have been seeking ways to preserve woman's fertility when treating invasive cervical cancer. For some women with small localized invasive cervical cancers, there is now hope for pregnancy after treatment. Many cases of cervical cancer are diagnosed in young woman who wish to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. The standard surgical treatment for stage IA2-IB1 cervical cancer is a radical hysterectomy and bilateral pelvic lymphadenectomy. This surgery includes removal of the uterus and cervix, radical resection of the parametrial tissue and upper vagina, and complete pelvic lymphadenectomy. Obviously, the standard treatment does not allow future childbearing. Radical trachelectomy is a fertility-sparing surgical approach developed in France in 1994 by Dr. Daniel Dargent for the treatment of early invasive cervical cancer. Young women wishing to bear children in the future may be candidates for fertility-preservation options. The radical trachelectomy operation has been described and performed abdominally, assisted vaginally by laparoscopy and robotically. In this review we discuss the selection criteria for radical trachelectomy, the various possible techniques for the operation, the oncological and obstetric outcomes, and common complications.

Study Objective: To demonstrate the prevalence of endometriosis in the intrapelvic portion of the round ligaments of the uterus (RLUs) and to propose criteria for their excision., Design: Retrospective case series analysis of women undergoing laparoscopy for the treatment of deep infiltrating endometriosis (Canadian Task Force classification II-3)., Setting: Tertiary referral hospital., Patients: We evaluated 174 patients who underwent laparoscopy for the treatment of deep infiltrating endometriosis (DIE) between April 2006 and May 2009., Interventions: All patients underwent laparoscopy for the treatment of DIE and had their RLUs removed when there was shortening, deviation, or thickening. After removal, the RLUs were sent for histopathologic analysis to verify the presence or absence of endometriosis., Measurements and Main Results: The prevalence of endometriosis in the RLUs and the association between the macroscopic alterations and the anatomic pathology results were determined. After the identification of macroscopic alterations, 1 or both RLUs (for a total of 42) were removed from 27 of the 174 patients who underwent laparoscopy. The positive predictive value (PPV) of the macroscopic criteria proposed for endometriosis of the RLU was 83.3% (95% confidence interval [CI] = 72.1%-94.5%), with 35 positive RLUs out of the 42 that were excised. The prevalence of endometriosis of the RLU was 13.8% (95% CI = 8.7%-18.9%), with 24 patients having a positive histopathologic examination result for endometriosis., Conclusions: The prevalence of RLU endometriosis in patients with DIE was 13.8%, which emphasizes that a rigorous evaluation of this structure must be part of the routine surgical treatment of patients with endometriosis., (Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.)

Laparoscopic repair of pelvic organ prolapse in patients with ventriculoperitoneal shunts has not been previously described. The optimum management of patients with ventriculoperitoneal shunts undergoing laparoscopy is uncertain. We describe the case of a 21-year-old female patient with spina bifida and ventriculoperitoneal shunt who underwent laparoscopic hysteropexy for severe pelvic organ prolapse. The implications of performing laparoscopy on patients with ventriculoperitoneal shunts are reviewed along with strategies to reduce potential intraoperative complications.

Introduction and Hypothesis: In this study, we provide a description of laparoscopic uterine suspension technique through round ligament., Methods: From 1997 to 2010, 55 patients with uterine prolapse were treated by laparoscopic uterine suspension. It is performed by suturing and tying a 1-0 Ethibond on the left round ligament at its insertion into the uterus. Then curved forceps pass the lateral puncture wound into the extraperitoneal space along the round ligament and penetrates the anterior leaf of the broad ligament into the peritoneal cavity and grasps the free ends of the Ethibond. They are withdrawn extraperitoneally along the round ligament then tightly tied at the fasciae on either side of the lateral puncture wound., Results: Forty-two out of 55 patients (76.4%) experienced a reduction of prolapse to stage 0, regardless of what stage they started from. Twelve out of 55 (21.8%) experienced a reduction of prolapse varying from one to two stages. One out of 55 (1.8%) experienced no reduction in prolapse., Conclusions: This technique reconstructs a new, inelastic round ligament.

Seborrheic inclusion cyst is an unusual variant of epidermal cyst characterized by parietal histology similar to seborrheic keratosis. Cysts with such changes have been called "seborrheic keratosis-like changes in epidermal cyst" or "epidermoid cyst with seborrheic verruca-like cyst wall" or simply "seborrheic cyst". To date, this lesion has been described exclusively in cutaneous sites. We describe the first case of an extracutaneous seborrheic inclusion cyst arising from round ligament. A 30-year-old female was referred to our institution for abdominal pain. Ultrasonography showed a hypoechoic heterogeneous, round mass adjacent to the lower extremity of the left ovary, measuring 4.5 cm in maximum diameter. Contrast-enhanced computed tomography of the pelvis in the venous phase showed a round (4.5 cm in diameter) cystic lesion with inhomogeneous fluid content in the side of the left large ligament and anterior to the homolateral adnexa. Laparoscopic resection of the mass was performed. Intraoperatively, an extraperitoneal glistening pelvic mass was discovered: the lesion was attached to the intrapelvic 1/3 middle portion of the left round ligament. Macroscopically, the mass measured 6 cm x 6 cm x 3.5 cm and exhibited a smooth and glistening external surface. On cut sections, the mass was an unilocular cyst filled with soft, yellow, amorphous material. Histologically, the cystic wall was lined by a stratified squamous epithelium with a granular cell layer. The cavity contained keratin-like material. The cystic wall showed numerous areas with close-set basaloid cells and pseudohorn cysts. The latter aspect consisted of cystic invaginations of the epithelium filled with surface keratin, which in a given microscopic section may be cut in cross-section, thereby appeared as "cysts" within the involved epithelium. Parietal rupture was present, accompanied by granulomatous inflammation. There were no postoperative complications, and the patient was discharged 3 days after the procedure. The present case is unique in that it is the first reported case of an extracutaneous seborrheic inclusion cyst arising from a very unusual site, namely the round ligament. The site of origin of the lesion and its cystic nature were established by computed tomography findings. Conservative treatment with enbloc resection was possible. Histological examination confirmed computed tomography findings. The present report described a lesion typically found in dermatopathology practice, but which had arisen in an extracutaneous site.

Objective: To study the diagnosis and treatment of inguinal endometriosis., Study Design: A retrospective study was made of 9 patients presenting with inguinal endometriosis between January 1986 and November 2008., Results: The incidence of inguinal endometriosis was 0.07% among a total of 13,352 patients with endometriosis treated. Eight of 9 patients (88.9%) had lesions on the right side. The symptoms in 6 patients fluctuated with menses. Only in 3 of them with cyclic symptoms was inguinal endometriosis suspected preoperatively. Symptomatic complaints ranged from 3 months to 10 years, with an average interval of 3 years. Eight patients received complete excision of inguinal lumps. One patient with a lump of 5 cm in diameter underwent a wide excision including the extraperitoneal portion of the round ligament. Four cases underwent pelvic exploration at the same time, and it revealed the coexistence of ovarian endometriomas. No one showed recurrence in the groin on follow-up of 19-96 months., Conclusion: Inguinal endometriosis is rare and often diagnosed accidentally. It is mostly right-sided and concomitant with pelvic endometriosis. The surgical procedure is complete excision of the mass. Pelvic exploration should be performed if necessary.

Perivascular epithelioid cell tumors (PEComas) are a group of rare mesenchymal tumors including angiomyolipoma, clear cell sugar tumor, lymphangioleiomyomatosis, and other unusual clear cell tumors at various locations. We describe a 45-year-old female patient presenting with a painless mass at the left lower abdomen. Computed tomography showed a circumscribed mass 8 x 7 x 8 cm in the left round ligament of the uterus. The provisional diagnosis was leiomyoma. The patient underwent initial laparoscopic excision. The histological and immunohistochemical diagnosis was malignant PEComa. She subsequently underwent laparoscopic radical excision of the residual left round ligament and surrounding tissue. At 18 months after surgery, she remained well without clinical and radiographic evidence of recurrent disease. According to this report, primary PEComa of the round ligament can mimic leiomyoma. Laparoscopic radical excision might be a feasible and safe alternative treatment of this tumor with a favorable outcome.

Background: Conventional open herniorrhaphy in children has been reported to have 0.3-3.8% recurrence and 5.6-30% postoperative contralateral hernia rates. We developed a unique technique to achieve completely extraperitoneal ligation of PPV without any skip areas under laparoscopic control. This report introduces our technique and results compared with the cut-down herniorrhaphy., Methods: A consecutive series of 1,585 children with inguinal hernia/hydrocele (1996-2006) was analyzed. In laparoscopic patent processus vaginalis (PPV) closure (LPC), an orifice of PPV was encircled with a 2-0 suture extraperitoneally by a specially devised Endoneedle and tied up from outside of the body achieving completely extraperitoneal ligation of the ring. The round ligament was included in the ligation, whereas the spermatic cord and testicular vessels were excluded by advancing the needle across them behind the peritoneum. Cut-down herniorrhaphy (CD), with or without diagnostic laparoscopy, or LPC was selected according to parental preference under informed consent., Results: Parents gave more preference to LPC (LPC in 1,257 children, CD in 308, and miscellaneous in 20). Age ranges were equal for both groups. Sex distribution showed female preponderance in the LPC group (44.8% vs. 26.6%, p < 0.001) and umbilical hernia/cysts were predominantly included in the LPC group (11.9% vs. 2.9%, p < 0.001). Mean operation times were equal for both groups for unilateral repair (28.2 +/- 9.2 for LPC vs. 27.8 +/- 13.5 for CD) and were shorter for bilateral repair in the LPC group (35.8 +/- 11.6 vs. 46.7 +/- 17.7). The incidence of postoperative hernia recurrence and contralateral hernia in the LPC group was 0.2% and 0.8%. Two children in the CD group had injuries to their reproductive system during the operation (0.6%)., Conclusions: The advantages of our technique include following: technically simple, short operation time, inspection of bilateral IIRs with simultaneous closure of cPPV, reproductive systems remain intact, routine addition of umbilicoplasty if desired, and essentially indiscernible wounds.

The phenomenon of accessory ovary, initially described in 1864, is extremely rare. We report a case of an accessory ovary in a round ligament with endometriosis. At the time of laparoscopy a firm 2- to 3-cm mass was noted within the round ligament with a normal ovary visualized. Dissection and removal of the mass was performed. Histopathology revealed ovarian stroma and dense connective tissue with endometriosis. This case fulfills the criteria established in 1959 for accessory ovary and is the first case of an accessory ovary reported within the round ligament. A unique finding with the accessory ovary in this case is the presence of endometriosis. No reported cases exist of endometriosis within an accessory ovary. This information may be pertinent for evaluation of dysmenorrhea when no endometrial implants are present, or with the persistence or recurrence of endometriosis and pain after a bilateral salpingo-oophorectomy.

Objective: The objective of the study was to assess whether cardinal-uterosacral ligament lateral vaginal cuff angle stitches at the time of total hysterectomy may assist in preventing subsequent apical vault prolapse., Study Design: Total hysterectomies without cuff angle stitches were performed in 7 unembalmed cadavers. Successive hanging weights of 1, 2, 3, and 4 kg were loaded against the vaginal cuff and distances moved were recorded. The same process was repeated after tying bilateral angle stitches., Results: Average distances pulled with 1, 2, 3, and 4 kg of traction against the cuff without angle stitches were 14.6 +/- 1.4, 19.1 +/- 1.7, 23.1 +/- 2.3, and 27.6 +/- 2.0 mm, respectively. After completing angle sutures, these distances were 13.1 +/-1.1, 17.3 +/- 1.5, 20.9 +/- 1.9, and 25.1 +/- 2.6 mm, respectively (P = .026)., Conclusion: Methodical incorporation of the cardinal-uterosacral ligaments into the vaginal cuff margins at time of total abdominal hysterectomy may help minimize subsequent apical vault prolapse.

The abdominal actinomycosis (AA) is a rare and often unrecognised suppurative chronic illness. It is caused by an anaerobic Gram positive bacteria, Actinomyces israelii. Abdominal actinomycosis is responsible for pseudotumoral syndrome often leading, to a large and mutilating surgery whereas a prolonged treatment by antibiotics would have permitted to cure the disease. The diagnosis is obtained generally from anatomopathologic exam. We report four cases of abdominal actinomycosis being revealed by a pseudotumoral syndrome. The diagnosis was only made after surgery. In spite of an active treatment by antibiotics during several months, two of our patients had a relapse of the infectious process. These four observations confirm the diagnostic and therapeutic difficulties previously reported by other authors.

Round ligament varicosities during pregnancy are an important differential diagnosis of complicated inguinal hernias and have been reported only rarely. Diagnosis is reassuring and may prevent unnecessary surgical exploration. We describe a case of round ligament varicosities presenting during pregnancy that was readily diagnosed with Doppler sonography., ((Copyright) 2007 Wiley Periodicals, Inc.)

Study Objective: To evaluate the use of laparoscopic uterosacral ligament repair for long-term patient symptom improvement in patients with uterine prolapse or posthysterectomy vaginal vault prolapse and to evaluate how laparoscopic instrumentation kits facilitate procedure performance for the surgeon., Design: Nonrandomized, prospective, multicenter case series (Canadian Task Force classification II-2)., Setting: Five clinical sites consisting of 4 community hospitals and 1 university medical center., Patients: Seventy-two patients with stage II or worse uterine prolapse (58%, n = 42) or posthysterectomy vaginal vault prolapse (42%, n = 30). One patient with stage I vaginal vault prolapse was included in the group due to her significant symptoms., Interventions: Laparoscopic uterosacral ligament repair was performed on all patients; round ligament truncation was also performed selectively on patients with uterine prolapse. Fifty-seven percent (41 patients) had concomitant pelvic procedures., Measurements and Main Results: At 12-month follow-up, Pelvic Organ Prolapse Quantification (POP-Q) scores and patient self-reported symptom scores were significantly improved over baseline after laparoscopic repair of pelvic organ prolapse. Positive mean change in POP-Q score was 14.4 (p = .0003) for uterine prolapse repair and 9.28 (p = .017) for vaginal vault prolapse repair. Positive mean change in total symptom score was 20.36 (p <.0001) for uterine prolapse repair and 11.43 (p = .005) for vaginal vault prolapse repair. Surgeons reported a mean procedure time of 31.6 minutes for uterine prolapse repair and 21.7 minutes for vaginal vault prolapse repair. A mean rating of 7.5 was documented for ease of use for the uterine prolapse kit and 4.1 for the vaginal vault prolapse kit on a scale of 1 to 10., Conclusion: Laparoscopic uterosacral ligament repair improves symptoms and POP-Q scores over the long term in patients with uterine or vaginal vault prolapse. Laparoscopic instrumentation kits facilitate procedure performance for the surgeon with expedited surgery times.

Objective: To present preliminary results of a simple, minimally interventional, uterus-sparing procedure for uterine prolapse repair., Methods: This prospective study was undertaken on women with symptomatic uterine prolapse >/=2nd stage, who declined hysterectomy at the time of prolapse surgery. A 10 mm laparoscope and three 5 mm ancillary trocars were used to perform the procedure. The uterosacral ligament was invested with a nonabsorbable suture. A total of three helical type sutures were placed full-thickness in the uterosacral ligament, beginning in the distal third of the ligament. The ends of the suture were tied with an extra-corporeal knot-tying technique on each side, thus shortening the ligaments. Finally, the round ligaments were plicated to restore the uterus to its correct anatomic position. No additional surgical procedure was performed concomitantly., Results: Ten patients underwent laparoscopic uterosacral ligaments plication for the treatment of symptomatic uterine prolapse. The median (range) patients age was 45.5 years (36-66). Five (50%) patients were premenopausal and 3 (60%) had not completed their family. The median operating time was 22.5 min (20-45). No intraoperative complications occurred. The median follow-up time was 21 months (range 15-33). The median postoperative difference in POP-Q point C was -3 cm (range 0 to -5). Eight (80%) patients were objectively cured at the last follow-up evaluation and all of them reported a complete resolution of their symptoms. Two women had prolapse recurrence and underwent vaginal hysterectomy 7 and 24 months after primary surgery, respectively., Conclusion: Laparoscopic uterosacral ligaments plication is a minimally invasive and straightforward simple procedure that appears to be a safe and effective treatment option for women with uterovaginal prolapse who desire uterine preservation.