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Background: Cesarean sections are the most common abdominal surgical interventions worldwide, with increasing rates in both developed and developing countries. Postpartum (hemorrhage PPH) during cesarean sections can lead to maternal morbidity, prolonged hospital stays, and increased mortality rates. Although various non-surgical measures have been recommended for PPH prevention, surgical techniques such as uterine artery ligation and embolization have been used to manage PPH effectively., Objective: This study aimed to evaluate the effectiveness of a surgical technique based on the temporary bilateral clamping of uterine arteries to reduce blood loss during cesarean sections., Methods: A longitudinal prospective, randomized, controlled study was conducted with a preliminary population group of 180 patients at the University Hospital Regional de Málaga from November 2023 to January 2024. The study protocol was approved by the Ethics Committee of the Regional University Hospital of Malaga (protocol 1729-N-23 and registred with ISRCTN15307819|| http://www.isrctn.org/ , Date submitted 12 June 2023 ISRCTN 15307819). The patients were divided into two groups based on whether the clamping technique was applied during their cesarean sections. The study assessed hemoglobin levels before and after surgery, hospitalization durations, and the prevalence of anemia at discharge as the primary outcomes., Results: The patients who underwent the clamping technique demonstrated significant reductions in hemoglobin differences (0.80 g/dL) compared to the control group (1.42 g/dL). The technique also resulted in shorter hospital stays (3.02 days vs. 3.90 days) and a lower prevalence of anemia at discharge (76.2% vs. 60%)., Conclusion: Temporary clamping of uterine arteries during cesarean sections appears to be an effective measure for preventing postpartum hemorrhaging, reducing hospital stays, and decreasing the prevalence of anemia at discharge. Further research with larger sample sizes and standardized indications is warranted to confirm the benefits and potential broader applications of this technique., Trial Registration: ISRCTN 15,307,819., (© 2024. The Author(s).)

Rationale: Uterine arteriovenous fistula (UAVF) is a rare vascular abnormality that can cause severe and potentially life-threatening hemorrhage. Uterine artery embolization is a common treatment that may affect ovarian and uterine perfusion and cause fertility problems. We herein report our experience treating 2 patients with UAVF who underwent resection after temporary occlusion of both internal iliac arteries., Patient Concerns: Both patients presented with a large UAVF after incomplete miscarriages in the second trimester. Magnetic resonance imaging revealed a UAVF measuring 3.6 × 2.6 × 2.1 cm over the myometrium of the posterior uterine in case 1, and a UAVF of 7.1 × 4.1 × 4.5 cm was identified in case 2., Diagnosis: Uterine arteriovenous fistula, retained products of conception., Interventions: The patients underwent resection of UAVF with temporary occlusion of the internal iliac arteries and hysteroscopic removal of the retained products of conception., Outcomes: Intraoperative bleeding were minimal. Neither patient exhibited abnormal uterine bleeding at the 6-month follow-up. Follow-up ultrasonography and magnetic resonance imaging showed normal uterine myometrium and endometrium and no residual disease., Lessons: UAVF resection after temporary occlusion of the internal iliac arteries is a promising treatment approach for UAVF. This technique can reduce intraoperative bleeding and remove the potential hemorrhage-related lesion while preserving fertility., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

The aim of the study was to study robotic cervical radical trachelectomy, aimed at standardizing and optimizing surgical procedures, thereby facilitating the learning process. All surgical procedures were based on the anatomy of the embryonic compartments, which not only help prevent tumor spillage due to disruption of the embryonic compartments, but also maximize the avoidance of inadequate resection margins. Using robotics to perform radical trachelectomy, combined with the concept of membrane anatomy, not only enables a bloodless surgical process, but also streamlines and simplifies the procedure, making it more efficient and precise. Utilizing robotics for radical hysterectomy can lead to a more meticulous and refined outcome. Precise surgical techniques contribute to standardizing and optimizing surgical procedures, thereby facilitating the learning process., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Performing a minimally invasive surgery comes with a significant advantage regarding rehabilitating the patient after the operation. But it also causes difficulties, mainly for the surgeon or expert who performs the surgical intervention, since only visual information is available and they cannot use their tactile senses during keyhole surgeries. This is the case with laparoscopic hysterectomy since some organs are also difficult to distinguish based on visual information, making laparoscope-based hysterectomy challenging. In this paper, we propose a solution based on semantic segmentation, which can create pixel-accurate predictions of surgical images and differentiate the uterine arteries, ureters, and nerves. We trained three binary semantic segmentation models based on the U-Net architecture with the EfficientNet-b3 encoder; then, we developed two ensemble techniques that enhanced the segmentation performance. Our pixel-wise ensemble examines the segmentation map of the binary networks on the lowest level of pixels. The other algorithm developed is a region-based ensemble technique that takes this examination to a higher level and makes the ensemble based on every connected component detected by the binary segmentation networks. We also introduced and trained a classic multi-class semantic segmentation model as a reference and compared it to the ensemble-based approaches. We used 586 manually annotated images from 38 surgical videos for this research and published this dataset.

Objective: We investigated the efficacy of a combination of laparoscopy and bilateral uterine artery occlusion (BUAO) for the treatment of type II cesarean scar pregnancy (CSP)., Methods: Patients with type II CSP underwent laparoscopy + bilateral uterine artery embolization (control group) or laparoscopy + BUAO (study group). Data regarding the duration of surgery, intraoperative hemorrhage, postoperative complications, the duration of the hospital stay, and the costs of hospitalization were retrospectively collected. One year later, the time to the return of the β-human chorionic gonadotropin (β-hCG) concentration to normal and to the return of menstruation were compared., Results: The duration of surgery, time to the return of menstruation, and incidence of postoperative complications in the study group were significantly less than in the control group, but there was no significant difference in the time for β-hCG to return to normal or the volume of intraoperative hemorrhage. The duration of hospitalization and costs for the control group were higher than those for the study group., Conclusion: Laparoscopy in combination with BUAO is associated with minimal trauma, rapid recovery, a short duration of surgery, low cost of hospitalization, and a low postoperative complication rate. Thus, it represents a useful new surgical treatment for type II CSP., Competing Interests: Declaration of conflicting interestThe authors declare that there is no conflict of interest.

Objective: To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery., Design: Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval., Setting: Teaching hospital., Patient(s): A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines., Intervention(s): A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO 2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL., Main Outcome Measure(s): Not applicable., Result(s): The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy., Conclusion(s): Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner., Competing Interests: Declaration of Interests J. Baekelandt discloses consultancy for Applied Medical. J.S. has nothing to disclose. J. Bosteels has nothing to disclose. A.S. discloses educational work for Applied Medical., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time., (© 2024. The Author(s).)

Large loop excision of the transformation zone is an extremely common procedure routinely carried out in a gynaecology or colposcopy outpatient setting under local anaesthetic. Here, we present a rare case resulting in emergency hysterectomy. A healthy para 3, who had been diagnosed with microscopic cancer of the cervix, attended colposcopy for repeat excision. The colposcopy revealed a normal cervix, and diathermy loop excision was performed. During the procedure, heavy bleeding from the anterior cutting edge was noted. Despite the best attempts to manage the haemorrhage conservatively in outpatients, the bleeding persisted, and the patient was transferred to theatres. Examination under anaesthesia revealed an injury to the descending branch of the uterine artery, and emergency hysterectomy was performed. Immediate recognition of an extremely rare complication, fast decision-making and a cross-disciplinary approach led to a satisfactory outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Transcervical resection of adhesion (TCRA) and postoperative adjuvant estrogen and progestin are the main treatments for cavity adhesions, but the recurrence rate after surgery is still high. It was showed that aspirin could promote endometrial proliferation and repair after TCRA in patients with severe cavity adhesions, but the effect on reproduction was uncertain., Objective: To assess the effect of aspirin on uterine arterial blood flow and endometrium in moderate and severe intrauterine adhesion after transcervical resection of adhesion., Methods: The databases used included Cumulative Index to PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), and Wanfang database. Studies published before June 2022 were included. Each participant received an aspirin-based intervention aimed at improving uterine status, which was compared to a sham intervention. The primary outcome measure was a change in endometrium thickness. Secondary outcomes included uterine artery resistance index, blood flow index, and endometrial arterial resistance index., Result: A total of 19 studies ( n  = 1361 participants) that met the inclusion criteria were included in this study. The aspirin-based intervention was strongly associated with better clinical outcome at second-look endometrium thickness (MD 0.81, CI 0.46-1.16; p  < .00001) and blood flow Index (FI) (MD 4.1, CI 2.3-5.9; p  < .00001). Besides, the analysis of arterial pulsatility index (PI) showed a significantly reduced after transcervical resection of adhesion (MD -0.9, CI -1.2 to 0.6; p  < .00001); whereas no significant difference was found in endometrial arterial resistance index (RI) (95% CI, -0.30 to 0.01; p  = .07)., Conclusion: Our study proved the effect of aspirin on uterine arterial blood flow and endometrium in moderate and severe intrauterine adhesion after transcervical resection of adhesion. However, the review requires evidence from additional randomized controlled trials and high-quality research. More strictly designed research studies are needed to assess the effectiveness of aspirin administration after transcervical resection of adhesion.

Rationale: Uterine artery spontaneous rupture is a rare but potentially life-threatening complication during pregnancy and puerperium. The lack of typical symptoms makes it difficult to diagnose, which can result in serious consequences for both the mother and fetus., Patient Concerns: Case 1 presented with fainting and lower abdominal discomfort, while Case 2 developed hypotension after delivery and remained in poor condition even after rehydration., Diagnoses: Both cases were diagnosed with uterine artery spontaneous rupture, with intraoperative findings revealing ruptures in different branches of the uterine artery., Interventions: Both cases underwent surgical interventions, with laparoscopic surgery performed in Case 1 and repair of the ruptured artery in Case 2., Outcomes: Both cases had successful outcomes, with the ruptured arteries repaired and the patients discharged from the hospital within a week after surgery., Lessons: Uterine artery spontaneous rupture is a rare but potentially life-threatening complication that may present with atypical symptoms. Early diagnosis and prompt surgical intervention are crucial in preventing serious complications for both the mother and fetus. Clinicians should maintain a high level of suspicion for this condition when evaluating patients presenting with unexplained symptoms or signs of peritoneal irritation during pregnancy and puerperium., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Aim: To compare intraoperative and postoperative clinical results of laparoscopic and laparotomic myomectomy operations in patients with and without bilateral uterine artery ligation., Materials and Methods: A retrospective analysis of 217 patients with intramural ≥ 5 cm myoma who underwent laparoscopic (n = 100) or laparatomic (n = 117) myomectomy was conducted. The patients were grouped according to the number of uterine myomas removed (≤2 or > 2). Clinical results of both laparoscopic and laparotomic myomectomy methods and the presence of uterine artery ligation were compared. The recurrence of myomas and pregnancy outcomes were also reported., Results: For patients with > 2 myomas removed without uterine artery ligation, the amount of bleeding, operation time, and hospital stay were significantly lower in patients who underwent laparotomic myomectomy but no significant difference in patients with <2 myomas removed. The rate of hemorrhage was lower in both the laparoscopy and laparotomy uterine artery ligation groups. The recurrence rate of myomas ≤ 3 cm was higher in the laparoscopic myomectomy group (p = .022) and in patients without uterine artery ligation group (p = .028) but recurrence rates for myomas > 3 cm were similar between in groups. Pregnancy occurred in 24 of the 96 patients who underwent uterine artery ligation, and 14 pregnancies resulted in live births., Conclusion: Uterine artery ligation might be a suitable addition to myomectomy surgery to reduce intraoperative bleeding and the recurrence of myoma, especially in cases where more than two uterine myomas are removed laparoscopically., Key Words: Laparoscopic myomectomy, Laparotomic myomectomy, Myomas, Haemorrhage, Uterine artery ligation.

Objectives: The present study aimed to investigate the efficacy of ultrasonic dissectors for adenomyomectomy using the double/multiple-flap method combined with temporary occlusion of the temporary bilateral uterine artery and the utero-ovarian vessels for the treatment of symptomatic adenomyosis., Design: This was a retrospective study., Participants: In total, 162 patients with symptomatic adenomyosis were included, and all of them had originally been scheduled to group A (n = 82) and group B (n = 80) with each group representing a different surgical application. All eligible women were informed of the potential complications, benefits, and alternatives of each approach before they were assigned to one of the two groups, and patients chose group A or group B by themselves. In group A, we performed laparoscopic ultrasonic dissectors in adenomyosis with the double/multiple-flap method combined with temporary occlusion of the bilateral uterine artery and utero-ovarian vessels, while in group B, we performed adenomyomectomy with scissors. During the period of treatment, we evaluated operative time, intraoperative blood loss, and the degree of fatigue of surgeons' fingers., Results: The estimated blood loss, operative time, and the degree of fatigue of surgeons' fingers in group A were significantly lower than that in group B (p &lt; 0.001). No serious perioperative complications were observed in either group., Limitations: This was a retrospective study., Conclusion: The use of ultrasonic dissectors in laparoscopic adenomyomectomy with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels leads to improvements and releases the fatigue of surgeons' fingers in laparoscopic adenomyomectomy., (© 2023 S. Karger AG, Basel.)

Competing Interests: Declaration of competing interest “The authors have no potential conflicts of interest relevant to this article to declare.”

Study Objective: To demonstrate the "trick" knot, a technique of temporary ligation of the uterine artery at origin, a modification of the previously published "shoelace" knot., Design: A video demonstration., Setting: A private hospital., Intervention: Bilateral uterine arteries at origin are exposed after dissection of the peritoneum over the triangle formed by the round ligament, the infundibulopelvic ligament, and the pelvic sidewall [Video 1]. A 60-cm long free polyglactin absorbable suture with preformed knots at each end is introduced around the skeletonized uterine artery. Using a single throw, the "trick" knot is made by pulling out a loop of thread. The end is cut short, and the same suture is used to similarly ligate the other uterine artery. Each knot thus formed has a free end and a knotted end. Laparoscopic myomectomy is performed. On completion of the procedure, the knot is released by pulling the free end, restoring the blood supply to the uterus., Conclusion: Bilateral uterine artery ligation, although an effective method to curb bleeding during a laparoscopic myomectomy, when performed permanently, may lead to undesirable outcomes in women who wish to preserve fertility [1-3]. Methods for temporary ligation of the uterine artery at origin, such the removable vascular clips, are thus regarded justifiable [4]. In contrast to the removable "shoelace" knot, which uses a loop to make a throw, the technique of performing the "trick" knot mimics the steps of forming a regular intracorporeal knot [5]. This makes the latter technically easier and hence faster to perform, while still being as economic and reproducible as the former., (Copyright © 2022 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate a laparoscopic technique to remove a scar pregnancy., Design: Stepwise demonstration of the surgical technique., Setting: Santa Croce and Carle Hospital, Cuneo., Intervention: Patient B.B. is a woman referred to our center for a suspected cesarean scar pregnancy (CSP) at 9 weeks gestation. CSP occurs approximately in 6% of all ectopic pregnancies. The estimated incidence is reported to be 1:1800 to 1:2500 in cesarean deliveries. Depending on its location, CSP can be categorized as either type 1, if the growth is in the uterine cavity, or type 2, if it expands toward the bladder and the abdominal cavity. If inadequately managed, it can lead to severe complications; most of them are hemorrhagic and can threaten the woman's life. There are several therapeutic approaches: local excision seems to be the most effective choice in type 2 CSP. In expert hands, the laparoscopic approach is perhaps the best surgical choice as tissue dissection, electrosurgical hemostasis, and vascular control can be effectively managed with minimal invasive access. Because severe intraoperative bleeding can occur, retroperitoneal vascular control is mandatory in this surgery. In type 1 CSP curettage, aspiration or hysteroscopic approach can be considered if the CSP is of small dimensions. A hysteroscopic approach can also be helpful in type 2 CSP during the laparoscopic removal, as intrauterine guidance. A potassium chloride local injection can be considered in a preoperative stage in the presence of a fetal heart rate. The systemic administration of methotrexate is usually ineffective as single agent, but it can be useful if administered as adjuvant therapy. Uterine artery embolization can be useful in an emergency setting to manage severe bleeding, but it can lead to complications in subsequent pregnancies and, more rarely, to premature ovarian failure. Considering poor bleeding at presentation, feasible dimensions, and the woman's desire for future pregnancy, ultrasound-guided aspiration and curettage was attempted. Because endouterine removal was incomplete, methotrexate injection was proposed as adjuvant therapy, but the administration was postponed as the patient tested positive for coronavirus disease 2019. A month later, beta-human chorionic gonadotropin level dropped from over 16 000 to 271 mU/mL, so an ultrasound and biochemical follow-up was performed. A month later, despite a low beta-human chorionic gonadotropin value, an increase in dimensions was observed at ultrasound, so surgical laparoscopic removal was offered. In this video article, laparoscopic removal of scar pregnancy is discussed in the following surgical steps: (1) Temporary closure of uterine arteries at the origin, using removable clips. (2) Retroperitoneal dissection to safely manage the scar pregnancy. (3) Dissection of the myometrial-pregnancy interface. (4) Double layer suture on the anterior uterine wall., Conclusion: Laparoscopic surgical management is a very effective surgical approach to remove CSP. Knowledge of retroperitoneal dissection and vascular control is necessary to carry out this surgical intervention safely and effectively., (Copyright © 2022 AAGL. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Lateral occlusion prior to TLH has been suggested to reduce perioperative bleeding, operative time, and hospital stay. Furthermore, reducing the amount of bleeding and the length of the operation may affect parameters such as postoperative pain and the number of patients with postoperative vaginal vault hematoma., Methods: This RCT was conducted at a single center at Odense University Hospital in Denmark. Between February 2016 and February 2019, a total of 58 patients undergoing TLH and bilateral salpingectomy for benign cases were recruited to the study., Results: The mean operating time was significantly longer in the LA group with a mean difference between the two groups of six minutes. No other discrepancy regarding the primary outcomes was observed between the two groups. Total blood loss was similar in the two groups as well as the average hospital stay and the VAS score during the first seven days. 93% of the patients were discharged from the hospital within the first 24 h postoperatively., Conclusion: This RCT demonstrates that lateral occlusion of the uterine artery prior to TLH does not improve outcome for the patients and should therefore not be used as a standard procedure., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

An alternative surgical technique with closure of the uterine artery at its origin, known as lateral approach prior to TLH, has been proposed and it may offer important benefits to both patients and surgeons. Our objectives were to review the current literature regarding surgical outcomes between lateral and conventional approach in relation to TLH. We followed the 'PRISMA' guidelines and conducted a systematic review, which involved searching PubMed and Embase databases for RCTs evaluating the topic. We identified four RCTs including 585 patients. Three of the four studies reported a significant lower bleeding during TLH with prior lateral approach. Operative time was also shorter in the lateral approach group compared to the conventional approach group in three studies.Our review provides evidence that lateral occlusion of the uterine arteries prior to total laparoscopic hysterectomy may be beneficial due to less blood loss and shorter perioperative time without compromising patient safety.

Background: The proximity of the uterus and the cervix to the urinary tract predisposes the latter to injury during obstetrical and gynaecological surgical procedures. Following a difficult surgical procedure on the lower uterine segment and or adnexa, urinary tract injury should be excluded., Methods: A booked 39-year-old G3P2 lady who suffered an ischaemic stroke in the index pregnancy had a caesarean delivery at 39 weeks of gestation and sustained an extensive tear that extended inferiorly on the left lateral aspect of the uterus and this resulted in postpartum haemorrhage. Following the repair of the tear, uterine artery ligation was performed to achieve haemostasis., Results: Postoperatively, conventional ultrasonography which was performed to exclude ureteric injury suggested left hydronephrosis and a preliminary report of computerized tomography (CT) showed the same finding. The patient subsequently had left ureteric stenting. The final report of the CT scan was delayed but showed a simple left renal cyst and no hydronephrosis., Conclusion: Renal cyst is a differential diagnosis of hydronephrosis. Delayed availability of the final result of medical investigations jeopardises patients' safety. A preliminary imaging report is prone to error and its use to determine the indication for an invasive procedure should be limited to emergencies., (© 2022 Ngene NC.)

Objectives: Post-partum hemorrhage (PPH) continues to be the leading cause of maternal mortality in low-resource settings. The commonest variant - Atonic PPH, is managed by additional pharmacological measures which may fail. Additional surgical interventions for hemostasis take time and are not universally available. Immediate arrest of bleeding was deemed essential and a novel Transvaginal Uterine Artery Clamp (TVUAC) was explored for its effectiveness in achieving immediate hemostasis in atonic and mixed post-partum hemorrhage., Study Design: A retrospective chart review was performed for all patients, who underwent vaginal delivery and developed immediate post-partum atonic PPH, in a tertiary care center in South India, between 1st April 2015 and 31st December 2020. As soon as excess bleeding was observed, two TVUACs were applied trans-vaginally at 3' and 9'o clock position of the cervix to occlude the uterine arteries where it joins the isthmus of the uterus., Results: Of 3999 vaginal deliveries, there were 251 patients who developed primary atonic PPH during the study period, of which 89 were managed by medical measures alone. Out of the remaining 162 patients, in 153 (94.4%) TVUAC helped to achieve hemostasis; with TVUAC alone in 120 patients (78.43%) and with an additional second line surgical intervention in 33 patients. In nine patients, TVUAC was not readily available and hence second line interventions alone were used. None required any third line surgical interventions (laparotomies) for hemostasis nor were there any incident of maternal mortality or consumptive coagulopathy. TVUAC was applied for a mean duration of 25 ± 10 min. Only 11.6% (29/251, 95% C.I 7.9-16.1%) of the patients required a blood transfusion with a median of 2 (1-4) units of packed RBC. No procedure related complications were reported up to a scheduled 6th week in-person follow-up., Conclusion: The novel TVUAC shows potential in limiting third line interventions, maternal morbidity and mortality. Its effectiveness and safety may be further explored as a first line surgical adjunct to medical measures, in PPH protocols in low-resource settings., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: To investigate the efficacy of uterine artery ligation (UAL) and uterine artery embolization (UAE) in the treatment of uterine asthenia postpartum hemorrhage (PPH) after cesarean section and its effect on uterine and ovarian artery blood flow and function., Methods: 100 patients with uterine asthenia PPH after cesarean section in our hospital from January 2018 to November 2020 were randomly divided into 50 cases in the UAL group and 50 cases in the UAE group. They were followed up for 12 months. The bleeding volume, operation time, immediate hemostasis rate, and hemostasis effective rate; lochia clearance time and menstrual rehydration time; RI and S/D; and serum FSH, E2, and LH levels were compared between the two groups., Results: Compared with the UAL group, the amount of bleeding in the UAE group was significantly increased and the operation time was significantly shortened ( p < 0.05). There was no significant difference in the immediate hemostatic rate and hemostatic effective rate between the two groups ( p > 0.05). There was no significant difference in lochia clearance time and menstrual rehydration time between the two groups ( p > 0.05). There was no significant difference in RI and S/D between the two groups ( p > 0.05). Compared with before the operation, the levels of FSH and LH in the two groups decreased significantly, and the level of E2 increased significantly ( p < 0.05). There was no significant difference between the two groups ( p > 0.05)., Conclusion: The efficacy of UAL and UAE in the treatment of PPH with uterine asthenia after cesarean section and its effect on the blood flow and function of uterine and ovarian arteries are equivalent, but the amount of bleeding in UAL is less and the operation time of UAE is shorter. The appropriate operation method can be selected according to the actual situation., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Wufen Liu and Wei Yin.)

Aim: The aim of this study was to compare the surgical outcomes between patients who were staged laparoscopically for early-stage endometrioid-type endometrial cancer (EC) between those who underwent prophylactic ligation of uterine arteries (UAs) prior to pelvic lymphadenectomy and the patients who were operated with standard procedure., Methods: This retrospective study was conducted in women diagnosed with early-stage and low/intermediate-risk endometrioid-type EC. The control group included patients who underwent standard laparoscopic pelvic lymphadenectomy and the study group concerned patients who underwent prophylactic ligation of UA prior to pelvic lymphadenectomy. The prophylactic ligation of UA procedure was performed at a point just proximal to its origin., Results: The mean lymph node count dissected in the study group was higher in terms of statistical significance (17.5 ± 2.2 vs. 19.8 ± 3.6, p = 0.003 and p ˂ 0.05). The rate of the patients who had a positive pelvic lymph node detected did not differ between groups (7.4% vs. 16.7%, p = 0.258 and p ˂ 0.05). The operation time (OT) of the patients in the study group did not differ between groups (p = 0.546 and p ˂ 0.05). Hemoglobin drop (-0.5 ± 0.7) and hematocrite drop (-0.8 ± 0.9) values in the study group were found to be lower in the study group (p = 0.000, p = 0.000, and p ˂ 0.05)., Conclusions: Performing prophylactic ligation of UA at its origin prevents unwanted bleeding and facilitates the laparoscopic pelvic lymphadenectomy procedure., (© 2021 Japan Society of Obstetrics and Gynecology.)

Objective: The present study assessed the safety and benefits of laparoscopic-assisted adenomyomectomy compared to laparoscopic or laparotomic adenomyomectomy., Materials and Methods: This study was a retrospective comparative study. A total of 277 patients underwent adenomyomectomy between January 2016 and January 2019 at the Department of Obstetrics and Gynaecology, Ulsan University Hospital, including 25 with laparoscopic-assisted adenomyomectomy, 82 with laparoscopic adenomyomectomy, and 170 with laparotomic adenomyomectomy. Laparoscopic-assisted adenomyomectomy consisted of a laparoscopic uterine artery procedure to reduce blood loss and a minimal incisional for laparotomic adenomyomectomy. An additional laparoscopic surgery was performed for possible pelvic pathology., Results: Data on patient demographics, surgical indications, operative times, estimated blood loss (EBL), short-term complications, and postoperative hospital stays were compared. The laparoscopic-assisted surgery (LAS) and laparotomic groups were comparable in average EBL (208.0 ± 128.8 vs. 193.6 ± 193.0 ml, p = 0.11), weight of removed mass (85.5 ± 71.7 vs. 108.2 ± 91.9 g, p = 0.39), and postoperative hospital days (HDs) (4.5 ± 1.0 vs. 4.7 ± 0.8 days, p = 0.27). These values were lower in the laparoscopic group (EBL 119.5 ± 79.6 ml, mass weight 39.3 ± 25.9 g, HD 3.6 ± 0.8 days). Additional procedures, including myomectomy and combined severe endometriosis surgery, were more frequently performed in the LAS group than the laparotomic group. The mean operating time was longer in the LAS group (179.8 ± 36.6 min) than the other groups (laparoscopy 99.9 ± 40.6 min, p < 0.00; laparotomy 133.0 ± 41.1 min, p < 0.00). The three groups did not differ significantly in transfusion rates, hemoglobin changes, or perioperative complications. However, febrile morbidity was lower in the laparoscopic group than the LAS and laparotomic groups., Conclusion: LAS adenomyomectomy allows for maximal debulking of adenomyosis via extracorporeal and intracorporeal procedures while retaining the advantages of the laparoscopic approach. Additional pelvic surgery for benign uterine and adnexal pathology may easily be performed with this approach., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest and nothing to disclose., (Copyright © 2021. Published by Elsevier B.V.)

Objective: Adenomyosis usually causes dysmenorrhea and anemia. Clinically, it is difficult to be treated with medicine or by traditional surgery, however, hysterectomy is always performed for radical treatment. In this article, we introduce a new method that could control the dysmenorrhea and the anemia through laparoscopic uterine artery occlusion (LUAO) combined with uterine-sparing pelvic plexus block and partial adenomyomectomy for uterus preservation., Design: Surgical video article. Local institutional review board approval for the video reproduction was obtained., Setting: A 42-year-old patient, who had a history of a previous cesarean delivery, was admitted to our department with complaints of progressive dysmenorrhea for more than 5 years and aggravated with anemia for 1 year. The patient had failed treatment with traditional Chinese medicine and gonadotropin-releasing hormone and had to take painkillers for nearly half a year. The patient had no desire for another pregnancy. After careful consideration, the patient strongly rejected hysterectomy and demanded the preservation of the uterus, insisting on the integrity of the organs. A gynecologic examination showed that the uterus was hard and enlarged similar to one that is more than 8 gestational weeks, without tender nodules in the rectouterine pouch. The visual analog scale pain score was 7, and her hemoglobin was 93 g/L (after correction). The preoperative magnetic resonance imaging implied that there was 1 lesion in the posterior wall and the maximum diameter of the lesion was 7.8 cm., Interventions: We performed laparoscopic partial adenomyomectomy combined with occlusion of uterine artery to limit the amount of intraoperative bleeding, dissected the uterine branch of pelvic plexus nerve, and performed electrocoagulation blocking to relieve the dysmenorrhea. The specific operation procedures are as follows (Video): Firstly, we opened the peritoneum through Cheng's triangle, which contained the external iliac blood vessels, the round ligament, and the infundibulopelvic ligament (Fig. 1). Secondly, we separated the lateral rectal space and exposed the ureter, the internal iliac artery, the uterine artery, and the deep uterine vein. Thirdly, we found that the pelvic plexus was located on the outside of the sacral ligament and was approximately 2 to 3 cm below the ureter, going against the sacral ligament and passing through below the deep uterine vein (Supplemental Video 1). Fourthly, we separated the 4 layers of the paracervix [1]. The first layer included the internal iliac artery and the uterine artery. The second layer was the ureter. The third layer was the deep uterine vein. The last layer was the pelvic plexus, which involved the forward-going bladder branch, the inward-going uterine branch, and the downward-going rectal branch (Supplemental Video 2). These anatomic structures are similar to the complex architecture of an overpass called the Cheng's Cross [2] (Fig. 2). In this operation, only the uterine artery and the uterine branch would be blocked. Finally, we performed the partial adenomyomectomy. The endometrium, the myometrial tissues, and the serosa were repaired in some layers with continuous suture, depending on the depth of incision. The operation time was 92 minutes, and the intraoperative hemorrhage was approximately 50 mL. The patient was able to get out of bed on the first day after the operation and urinate after removing the catheter. On the second day after the surgery, the patient had exhaustion and defecation. From the third day after the surgery, gonadotropin-releasing hormone (Goserelin Acetate Sustained-Release Depot,3.6mg each, subcutaneous injection, name of the enterprise: AstraZeneca UK Limited) was used every 4 weeks, with a total of 3 times. Menstruation began on the 67th day after withdrawal of the drug. The results of postoperative condition of the patient followed up at 6 months after surgery were collected as follows: dysmenorrhea was significantly relieved (visual analog scale score was 2), hemoglobin was 123 g/L, and uterine volume was reduced to 43% of preoperative volume. The comparison of the patient's preoperative and postoperative magnetic resonance imaging showed that the uterus was approximately the same size as that of a woman of the same age, and the incision healed well (Fig. 3)., Conclusion: Adenomyosis is a common gynecologic disease, mainly occurring in women of childbearing age. Adenomyosis is defined as endometrial glands and stroma that invade the myometrium and is surrounded by chronical inflammation in the endometrium [3]. Secondary dysmenorrhea and menorrhagia are the most common chief complaints in patients with adenomyosis, among which dysmenorrhea is the most unbearable symptom [2]. In the past, we had always treated adenomyosis by hysterectomy [4]. With the continuous pursuit of quality of life, it is difficult to meet clinical needs through drugs and traditional surgical methods. Uterine sparing surgery is a current trend in the treatment of adenomyosis, which enables women to maintain fertility and avoid the effects of hysterectomy on sexual function and mental discomfort. Dysmenorrhea can be divided into peripheral dysmenorrhea and central dysmenorrhea. According to our previous studies on dysmenorrhea, the uterine branch nerve has a controlling effect on dysmenorrhea [2]. The purpose of pelvic plexus uterine branch ablation is to further relieve dysmenorrhea by blocking nerve conduction pathways. Therefore, we selectively blocked the uterine branch nerve to alleviate the dysmenorrhea of adenomyosis. The uterine artery controls 90% of uterine blood flow. According to our team research, LUAO is an effective method to treat symptomatic uterine myomas and adenomyosis. We investigated the morphologic change and apoptosis occurring in myomal and adjacent myometrial tissues after LUAO. We concluded that apoptosis through mitochondrial pathways may lead to reduction of the volume of myoma and myometrium and eventually relief of symptoms [5,6]. We speculated "single organ shock uterine" to explain uterine artery occlusion (UAO) mechanism, which was different from uterine artery embolization. The single organ shock theory of UAO can still inhibit the growth of myomas effectively. It is difficult to completely remove adenomyosis lesions during surgery, especially for diffuse adenomyosis. Therefore, in our team, we performed UAO combined with resection of focal lesions in key areas for patients with diffuse adenomyosis, instead of pursuing radical resection [7,8]. The purpose of UAO is to reduce the amount of bleeding during surgery and further atrophy of residual and scattered adenomyosis lesions in utero [5,6]. The intraoperative blocking of the uterine artery can reduce intraoperative bleeding and operation time, improve operation quality, and decrease recurrence rate. In our team, this technique has been used in clinic for more than 10 years. Our previous studies have shown that LUAO combined with pelvic plexus uterine branch nerve block and resection of most of the adenomyosis has achieved satisfactory clinical efficacy as a treatment for adenomyosis [2,3]. With this procedure, we can help patients with adenomyosis retain their uterus and relieve the anxiety caused by hysterectomy. In conclusion, UAO and uterine branch ablation in uterine sparing laparoscopic treatment is a safe and effective method, which may be considered as a good choice for symptomatic adenomyosis., (Copyright © 2021 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other., Material and Methods: We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, vs closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up., Results: Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] vs 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ., Conclusions: Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objectives: To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols., Search Strategy: PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021., Study Selection: Randomised and non-randomised comparative studies., Outcomes: Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy., Results: All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon., Conclusions: The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting., Tweetable Abstract: Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery., (© 2021 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Cervical ectopic pregnancy (CEP) is one of the rarest types of ectopic pregnancy. Early detection of such cases increases the chances of conservative treatment and fertility preservation. Within 6 weeks of each other, 2 women were admitted to the OB/GYN Department with cervical ectopic pregnancies. They were successfully treated with a double dose of methotrexate and super-selective uterine artery branch embolization (SUABE). Taking into account health and economic considerations, for instance the optimal recovery time, and lower costs of operating theater time, laboratory testing and outpatient observation, it seems that safe, minimally invasive, fertility-saving, effective systemic administration of MTX in combination with SUABE, can be a rational alternative to cervical ectopic pregnancy treatment.

Background: The formation of a uterine artery pseudoaneurysm is rare and isolated cases have been reported in the existing literature following caesarean sections, curettages and cone biopsies. There has been no report of pseudoaneurysm formation following a loop electrosurgical excision procedure. Vaginal bleeding could potentially be life threatening if this diagnosis is not considered following cervical instrumentation or surgery. Management options range from haemostatic sutures, image-guided embolisation to surgical repair. We report the diagnosis and management of a case of uterine artery pseudoaneurysm after a loop electrosurgical excision procedure., Case Presentation: A 37-year-old woman was diagnosed with cervical intraepithelial neoplasia grade 3 (CIN3) and underwent a therapeutic loop electrosurgical excision procedure. One month after the procedure, the patient presented to the emergency department with repeated episodes of sudden-onset heavy vaginal bleeding associated with hypotension and syncope. A computed tomography angiogram was performed, which demonstrated a pseudoaneurysm of the right uterine artery. Following the diagnosis, image-guided embolisation was performed successfully. Post-embolisation angiograms showed successful embolisation of the pseudoaneurysm and the patient had no further episodes of bleeding., Conclusions: Loop electrosurgical excision procedures are generally safe but rarely, can be complicated by the formation of uterine artery pseudoaneurysms. The depth of the loop electrosurgical excision procedure and vascular anatomy should be considered to prevent such complications. A computed tomography angiogram appears to be ideal for diagnosis. Image-guided embolisation is safe and effective as a therapeutic measure, with minimal morbidity., (© 2021. The Author(s).)

Objective: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality. Surgical interventions, such as uterine artery ligation and utero-ovarian arteries ligation (UAL and UOAL), are considered as effective methods to control PPH. Owing to PPH's severe outcomes, various educational tools have been developed to train surgical residents. A potential educational medium for this purpose could be serious digital games. In this pilot study, we assessed the usability and effectiveness of a serious game to promote the surgical skills of UAL/UOAL among obstetrics and gynecology (OB/GYN) residents. Methods: We designed and developed the Play and Learn for Surgeons (PLS) game to train OB/GYN residents. We assessed and compared the usability challenges of PLS before and after revising the game. To assess the effectiveness of PLS, residents were allocated randomly in control and intervention groups. Surgical skills of the residents were assessed pre- and post-test using the Objective Structured Assessment of Technical Skills checklist. Setting: This pilot study took place at the OB/GYN wards of Omolbanin Hospital (Mashhad University of Medical Sciences) and Imam Ali Hospital (Zahedan University of Medical Sciences) in Iran. Participants: Thirteen subject matter experts (nine OB/GYN experts and four senior clinical assistants) participated in the user interface design and usability assessment of PLS. Total of 46 OB/GYN residents participated in the educational effectiveness analysis of PLS. All participants were female with mean ages of 40.6, 29.9 and 28.0 years for OB/GYN experts, assistants, and residents, accordingly. Results: All participants completed the study. PLS significantly improved the skills of residents for UAL ( P -value = 0.018) and UOAL ( P -value <0.001) procedures. Conclusion: Serious games can be an effective and affordable approach in training OB/GYN residents for UAL and UOAL procedures. Approval number: (# IR.MUMS.fm.REC.1396.345) Trial registration number: (# IRCT2017092436366N1).

Objective: Uterine artery ligation (UAL) at the time of myomectomy has shown to decrease blood loss during the operation. However, little is known about the efficacy and feasibility of UAL during single-port access (SPA) myomectomy. The present study was performed to investigate the clinical benefits of UAL in SPA myomectomy and to provide details of the surgical techniques., Materials and Methods: A retrospective and comparative review on the surgical outcomes of the patients who underwent SPA myomectomy with UAL and those who underwent SPA myomectomy without UAL was conducted. UAL was performed at its origin from the internal iliac artery via a retroperitoneal approach., Results: A total of 56 women who received SPA myomectomy were reviewed (24 patients received SPA myomectomy with UAL while 32 patients received SPA myomectomy only). The median weight of total resected leiomyomas was heavier for the patients who received UAL than those who did not receive UAL [210.0 g (range: 171.5-335.0 g) vs. 119.0 g (62.5-265.0 g), p = 0.023]. However, no differences in total operative time, estimated blood loss, perioperative hemoglobin changes, use of postoperative analgesics and postoperative complications between the two groups were seen., Conclusion: Obtaining similar surgical outcomes between the patients who received UAL with larger leiomyomas and those who did not receive UAL with smaller leiomyomas suggests that UAL is a feasible surgical approach to reduce blood loss during SPA myomectomy. Detailed descriptions of the surgical techniques are provided in the present report., Competing Interests: Declaration of competing interest The authors of the present study declare no conflicts of interest., (Copyright © 2021. Published by Elsevier B.V.)

Background: To introduce the surgical procedure based on special space anatomy that can safely and efficiently complete the dissociation of the ureter and uterine artery during laparoscopic radical trachelectomy with uterine artery preservation. Methods: We introduce the key technique elements of this surgical procedure using a patient we treated as an example. A 27-year-old patient was diagnosed as well-differentiated cervical adenocarcinoma, stage IB1, and had a strong desire for future fertility. Laparoscopic radical trachelectomy with uterine artery preservation was performed in this patient by using this new surgical technique based on space anatomy. Results: The ureteral space that needs to be dealt with during laparoscopic radical trachelectomy is actually a potential avascular space located medial to the ureter between the anterior leaf (from the axillary space to the fourth space of Yabuki) and posterior leaf (between the paravesical space and paravaginal space) of the vesicouterine ligament. Exposure of the axillary space can help to separate the ureter from the lower uterine segment and uterine artery (uterine side), which is necessary for radical trachelectomy with uterine artery preserved. Multiple "shafts" called potential avascular space can be drilled on the anterior leaf of vesicouterine ligament, and the connective tissue and blood vessels between the "shafts" were cutoff with ultrasonic scalpel. After the paravesical space and paravaginal space were developed, the posterior leaf was isolated and congealed completely by Ligasure. Conclusions: In brief, this new surgical procedure consists of four spaces that can safely and efficiently perform complete excision of the vesicouterine ligament, reduce blood loss, avoid ureteral injury, and shorten the operation time.

Objective: To present a technique of temporary uterine artery clamping before laparoscopic surgery for prevention of blood loss in cornual ectopic pregnancy., Design: Step-by-step explanation of the entire surgical procedure using video and still images (Canadian Task Force classification III)., Setting: Tertiary university-based hospital., Patient(s): A 37-year-old woman who presented with amenorrhea of 55 days and extremely high β-hCG level of 281,400 mIU/mL. Transvaginal ultrasound examination revealed a 7 cm mass with ample blood supply invading the muscularis layer around the right uterine cornua., Intervention(s): Institutional Review Board and Ethics Committee approval was obtained. After pelvic adhesiolysis, retroperitoneum was dissected and the bilateral uterine arteries were exposed. To reduce the possibility of massive hemorrhage, titanium clips were used to temporarily block the bilateral uterine arteries. Laparoscopic inspection showed the mass as dark and blue, consistent with the diagnosis of cornual pregnancy. After removal of the cornual lesion, 2-0 Vicryl was used to reconstruct the uterine cornua. At the end of the surgery, the titanium clips were removed to reverse the uterine blood supply., Main Outcome Measurement(s): The surgery lasted for about 2 hours, with estimated blood loss of only 50 mL. The patient recovered completely and was discharged 2 days postoperatively, without any further bleeding or postoperative complications. The pathological examination confirmed the diagnosis of cornual pregnancy., Result(s): One month later, the β-hCG levels decreased to within normal range. At 6-month postoperative follow-up, ultrasound examination showed a normal size uterus., Conclusion(s): Temporary blockage of the uterine artery during surgery could prevent heavy blood loss, especially in difficult surgeries such as myomectomy for complex uterus fibromas or adenomyomectomy. Moreover, this technique would be feasible for emergent cases, including conservative surgery for cesarean scar pregnancy, and could also replace traditional uterine artery embolization for treating cornual pregnancy., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Pseudoaneurysm of the uterine artery (UPA) is a rare cause of potentially life-threatening hemorrhage during pregnancy and puerperium. It is an uncommon condition that mainly occurs after traumatic injury to a vessel following pelvic surgical intervention, but also has been reported based on underlying endometriosis. There is an increased risk of developing UPA during pregnancy. Diagnosis includes clinical symptoms, with severe abdominal pain and is confirmed by sonographic or magnetic resonance imaging (MRI). Due to its potential risk of rupture, with a subsequent hypovolemic maternal shock and high fetal mortality, an interdisciplinary treatment should be considered expeditiously., Case Presentation: We present the case of a 34-year old pregnant symptomatic patient, where a large UPA was detected at 26 weeks, based on deep infiltrating endometriosis (DIE). The UPA was successfully treated by selective arterial embolization. After embolization, the pain decreased but the woman still required intravenous analgesics during follow-up. At 37 weeks she developed a sepsis from the intravenous catheter which led to a cesarean section and delivery of a healthy boy. She was discharged 10 days postpartum., Conclusions: UPA should be considered in pregnant women with severe abdominal and pelvic pain, once other obstetrical factors have been excluded. DIE might be the underlying diagnosis. It is a rare but potentially life-threatening condition for mother and fetus.

Introduction: To evaluate the feasibility of uterine arteries prophylactic occlusion balloon placement (POBP) to reduce hemorrhagic complications associated with placenta praevia., Material and Methods: A retrospective analysis was carried out from January 2014 to November 2018. Only women with a diagnosis of placenta praevia and gestational age at delivery between 33 and 40 weeks were included. All women were diagnosed using transvaginal ultrasound scan (TVS) and confirmed with magnetic resonance imaging (MRI). All women underwent uterine arteries POBP before caesarean delivery (CD). All patients underwent clinical and instrumental follow-up with semestral outpatient TVS for 2 years after the surgery., Results: Forty-eight pregnant women were recruited and analyzed. 32/48 patients (66%) had positive anamnesis for previous CDs. Mean blood loss was 510 ± 222 mL. 15/48 patients (31.6%) were supported with RBC concentrate transfusion. In 10 (20.8%) cases, an intrauterine haemostatic balloon (Bakri-Balloon, Cook Medical, Spencer, USA) was used to control the intra-operative hemorrhage. Hysterectomy was performed in eight cases (16.6%). No cases of hemodynamic instability or urinary complications were reported. No postoperative complications occurred. During follow-up, no long-term complications were observed and nine patients had a successful pregnancy., Conclusions: Uterine arteries POPB is a promising technique that may be adopted in women with placenta praevia to prevent hemorrhagic complications.

Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We aimed to evaluate the effect of temporary ligation of the uterine artery on postpartum bleeding during uncomplicated cesarean section., Design: This was a prospective, randomized, and controlled study. We recruited a total of 200 patients, including 100 cases and 100 controls., Methods: The bilateral uterine artery was temporarily clamped 2 cm below the uterine incision in the study group and compared with controls. Patient demographics, the amount of intraoperative bleeding, the duration of the operation, the closure time of the uterine incision, the need for additional uterotonics, the need for additional sutures, and the hemoglobin values before and after birth were assessed., Results: The mean value of the amount of bleeding in the clamped and control groups was 267.3 ± 131.8 mL and 390.2 ± 116.4 mL, respectively. The amount of bleeding was significantly decreased for clamped group (p < 0.001). A significant reduction occurred in the results of pre- and postoperative values of hemoglobin and hematocrit difference, operation duration, and the closing time of the uterine incision in the experimental group which has temporary uterine artery clamping., Limitations: The cases of recurrent cesareans were not included in this study., Conclusion: Temporary uterine artery ligation can be used to reduce the amount of bleeding during uncomplicated cesarean delivery and prevent postpartum hemorrhage., (© 2021 S. Karger AG, Basel.)

Objective: To evaluate the outcome of preserving the ascending uterine artery in a modified fertility-sparing abdominal radical trachelectomy and understand whether preserving uterine arteries during abdominal radical trachelectomy is helpful for patients., Methods: From September 2005 to September 2019, 31 early uterine cervical cancer patients who underwent modified fertility-sparing abdominal radical trachelectomy were enrolled in this study, and were followed up in our cancer center. Computed tomography (CT) of the abdomen and pelvis was advised as the initial investigation to evaluate the ascending uterine artery in 11 patients. The major outcomes were recurrence, mortality, CT results and obstetric outcomes., Results: During the median follow-up of 56 months, two recurrences were recorded. Among 11 patients who underwent CT, none of them showed uterine arteries occlusion. Fifteen patients attempted to conceive, and 5 pregnancies were achieved in 5 patients. Hence, the pregnancy rate among patients who attempted to conceive was 33.3 %. There was only one artificial first-trimester abortion. Three pregnancies resulted in live births, and two of them got full-term births., Conclusions: The modified fertility-sparing abdominal radical trachelectomy in preserving uterine arteries is effective, and it is recommended that surgeon should retain the uterine artery as much as possible during operation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Study Objective: To determine and categorize the anatomic variations of the uterine artery (UA) as observed during laparoscopic hysterectomy with retroperitoneal dissection for benign conditions., Design: A prospective, observational study., Setting: A hospital department of obstetrics and gynecology, Uludag University Hospital, Bursa, Turkey., Patients: A total of 378 female patients who presented with indications for laparoscopic hysterectomy for benign disease., Interventions: Laparoscopic hysterectomy with retroperitoneal dissection was performed bilaterally in all patients between March 2014 and October 2018. The vascular anatomy beginning at the bifurcation of the common iliac artery down to the crossing of the UA with the ureter was exposed and subsequently studied. The UA was identified, and its variable branching patterns were recorded. The patterns were then categorized into groups adapted from classic vascular anatomy studies., Measurements and Main Results: Retroperitoneal dissections of 756 UAs were performed in 378 female patients. The UA was the first anterior branch of the internal iliac artery in 80.9% of the cases (Model 1; Main Model). Three additional models adequately described other variations of the UA as follows: Model 2 (Cross Model), 3.7%; Model 3 (Trifurcation Model), 3.1%; and Model 4 (Inverted-Y Model), 7.4%. The origin of the UA could not be determined in 7.4% of the cases., Conclusion: The UA is the first anterior branch of the internal iliac artery in more than 80% of females. Surgeons should be aware of the anatomic variations of the UA to perform safe and efficient procedures., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks' gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks' gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Trainees require extensive experience to perform radical hysterectomy. Before starting training during an actual operation, trainees should be familiar with the pelvic anatomy and should simulate surgical procedures. Many simulators are available for virtual reality training of laparoscopic operations, but they are very expensive. The materials required to construct our model included sponges and colored wires sold in home improvement stores that allowed for superior cost effectiveness. The model represented almost all peripheral vessels and nerves around the uterus, including the minor vessels. Attaching and detaching the vessels was easy, facilitating reconstruction of the dissected vessels. The wires were easy to bend, ensuring high operability. This model allows for the simulation of laparoscopic radical hysterectomy in a dry box. Our model was superior to a 2-dimensional picture for the memorization of branching and positional relationships of the blood vessels. Comparison of our model with actual operative videos showed that the dry box provided an identical surgical view of an actual laparoscopic radical hysterectomy. We developed a peripheral bloodstream model of the uterus for repeated simulation of laparoscopic radical hysterectomy with an actual surgical view using a dry box., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

BACKGROUND With the changes in China's family planning policy, the incidence of cesarean scar pregnancy (CSP) significantly increased in recent years. The present study aimed to investigate the clinical efficacy of combined hysteroscopic and laparoscopic surgery and reversible ligation of the uterine artery for cesarean scar excision and repair in patients with type II and III CSP. MATERIAL AND METHODS This was a retrospective study of 173 patients with type II and III CSP. They were assigned to the hysteroscopy and laparoscopy group (group A), hysteroscopy group (group B), and curettage group (group C) according to the surgery they underwent. The surgical indicators (intraoperative bleeding volume and hospital stay), postoperative recovery (time of serum ß-hCG returning to the normal, postoperative residual lesion, the thickness of the uterine scar, and recovery time of menstruation), and the postoperative complications were compared among the 3 groups. RESULTS In patients with type II and III CSP, significant differences (P<0.05) were observed between group A vs. groups B and C in terms of the time of serum ß-HCG returning to normal, postoperative residual lesions, the thickness of the uterine scar, and recovery time of menstruation, while there were no significant differences in intraoperative bleeding volume and postoperative hospital stay (P>0.05). CONCLUSIONS For patients with type II and III CSP, hysteroscopy and laparoscopy surgery and reversible ligation of the uterine artery achieved better clinical outcomes than hysteroscopy or curettage with respect to postoperative recovery. This could be suitable for patients with CSP and desire for fertility.

Introduction: Uterine transplantation (UTx) is a surgical therapeutic modality designed for the treatment of patients with exclusive uterine factor infertility. Experimental models are paramount to study this transplant modality, and as the ewes' uteri are very similar to that of humans, they are frequently used with this purpose. The aim of this study is to describe a novel technical variation for UTx in sheep., Methods: This study was conducted at Laboratory of Medical Investigation 37 of the University of São Paulo School of Medicine in São Paulo, Brazil, and was approved by the Ethics Committee of Animal Use of the university. We used 3 adult female sheep that weighed approximately 45 kg and were not pregnant. We performed the technique of uterine autotransplantation with a novel technical variation that we called sequential vascularization: first, we performed the right uterine artery and vein anastomoses, after which the uterine graft was vascularized, and then the contralateral vascular anastomoses were performed., Conclusion: We described 3 successful uterine autotransplants in sheep models with sequential vascularization. This variation technique will probably allow warm ischemia time in UTx to significantly decrease., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This investigation sought systematically to review and meta-analyze evidence on reproductive outcomes following uterine artery occlusion (UAO) at myomectomy. Databases searched included PubMed, EMBASE, Ovid MEDLINE, Web of Science, and ClinicalTrials.gov. Eligible studies included observational and randomized controlled trials in which patients underwent abdominal, laparoscopic, or robotic myomectomy and in which at least one measure of clinical pregnancy rate, live birth rate, or ovarian reserve was reported. The primary outcome was live birth rate. Secondary outcomes included clinical pregnancy rate, miscarriage rate, adverse pregnancy outcomes, and measures of ovarian reserve. Twelve articles involving 689 women were included in the systematic review. The intervention group underwent UAO at laparoscopic or abdominal myomectomy (UAO+M) (n = 470). The control group underwent myomectomy alone (n = 219). Seven articles involving 420 women were included in the meta-analysis (201 underwent UAO+M; 219 underwent myomectomy alone). Live births occurred in 54 of 201 (27%) women in the UAO+M group and in 74 of 219 (34%) women in the control group. Clinical pregnancies occurred in 73 of 201 (36%) women in the UAO+M group and in 102 of 219 (47%) control subjects. There was no difference in live birth rates (odds ratio 0.89; 95% CI 0.56-1.43; P = 0.51; 7 studies, 420 patients) or clinical pregnancy rates (odds ratio 0.81; 95% confidence interval 0.53-1.24; P = 0.33; 7 studies, 420 patients) between the UAO+M and control groups. Data on miscarriage rates, adverse pregnancy outcomes, and measures of ovarian reserve precluded meta-analysis. In conclusion, UAO at myomectomy is not associated with reductions in live birth or clinical pregnancy rates. Before routine use can be recommended in women desiring future fertility, more research is required on reproductive outcomes and effects on ovarian reserve., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: Laparoscopic uterine artery ligation may be performed during myomectomy or other uterine invasive procedures to reduce the amount of blood loss during surgery. In this video, the authors describe 3 different laparoscopic techniques to approach the uterine artery., Design: Step-by-step video demonstration of 3 different surgical techniques., Setting: Private hospital in Curitiba, Paraná, Brazil., Interventions: The main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure., Anterior Approach: The impression of the uterine vessels can usually be seen anteriorly and laterally to the uterine cervix. After identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be performed with extreme caution because the uterine veins are very close to the artery. Venous bleeding at this point of the dissection can be very difficult to control without ligating the vessels. After circumferential dissection of the artery, temporary occlusion is conducted using 2-0 polyester suture., Posterior Approach, Lateral to the Infundibulopelvic Ligament: For ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel and medial to the external iliac vessels toward the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection (traction and countertraction), identifying the lateral (external iliac vessels) and medial (pelvic infundibulum and the ureter attached to the peritoneum of the ovarian fossa) landmarks. The external iliac artery is dissected cranially to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac usually is the uterine artery. After circumferential dissection of the uterine artery, it may be ligated according to the same technique described above., Medial Approach: For the medial approach, the peritoneum should be opened medial to the infundibulopelvic ligament. The assistant grasps the infundibulopelvic ligament, creating a peritoneal tent. Immediately after broad ligament opening, anatomic landmarks are identified. First, the ureter is identified and medialized. For the identification of vascular anatomy, movement of the obliterated umbilical artery is made active, which reduces the risk of error to ligate the uterine artery. After circumferential dissection of the artery, it may be ligated according to the same technique described above., Conclusion: Laparoscopic uterine artery ligation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to the position of the myomas within the uterus as well as the uterine volume, the surgeon may choose among 1 of the above-mentioned techniques to perform. This technique could also be applied to other types of invasive uterine procedures to reduce blood loss. Standardization of these techniques could help to reduce the laparoscopic learning curve., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Uterine Arteriovenous Malformation is a rare gynaecological disorder which commonly presents with profuse vaginal bleeding. This case report presents a patient referred to the Military Hospital, Rawalpindi from Pakistan Aeronautical Complex Hospital Kamra, a peripheral secondary care hospital. Patient was diagnosed as a case of Uterine Arteriovenous Malformation at the Military Hospital and was successfully treated with uterine artery embolization..

Objective: This study aimed to determine risk factors associated with the failure of uterine artery ligation at its origin following development of the retroperitoneal space (UALr) and evaluated its efficacy in decreasing estimated blood loss (EBL) during single-port total laparoscopic hysterectomy (SP-TLH)., Materials and Methods: This study includes patient data collected prospectively from May 1st, 2013 to establish a registry for single-port surgery. Data for the present study were collected retrospectively from May 1st, 2013 to August 30th, 2016. Patients who underwent SP-TLH for a symptomatic benign disease. When bilateral UALr was performed successfully, the case was classified as part of the UALr success group. When only unilateral UALr was completed or UALr failed, the case was classified as part of the failure group. We compared patients' baseline characteristics and surgical outcomes between the two groups., Results: Bilateral UALr was successfully performed in 155 cases and failed in 64 patients. Body Mass Index (BMI) was significantly different between the two groups (24.1 kg/m2 vs. 22.86 kg/m2, p = 0.025). A BMI higher than 23.6 kg/m 2 was a risk factor for UALr failure in a multivariate analysis (odds ratio = 2.42, p = 0.004). EBL was significantly lower in the UALr success group compared to the UALr failure group (100 [100.0-200.0] vs. 200 [100.0-250.0], p < 0.001), and incidence of Hb decrease of more than 2 g/dl was higher in the UALr failure group (36.1% vs. 54.7%, p = 0.017)., Conclusion: We identified higher BMI as a risk factor for UALr failure and demonstrated the safety and efficacy of UALr in reducing blood loss during SP-TLH., Competing Interests: Declaration of Competing Interest The author(s) have no conflicts of interest relevant to this article., (Copyright © 2020. Published by Elsevier B.V.)