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INTRODUCTION The use of mesh for vaginal repairs is currently problematic and as a consequence, there is increased interest in native tissue repair. We describe the follow-up data of a sub-analysis of a prospective and multi-center study focusing on the combination of pectopexy and native tissue repair. Patients were followed up for 12-18 months after surgery (+ SD: 15). Two-hundred and sixty-four patients attended the clinics for physical examination and were integrated into the follow-up. Cystocele repair was performed laparoscopically in 84 patients and vaginally in 52 patients. Posterior repair was performed vaginally in 40 patients and laparoscopically in 53 patients. Results: Clinical success rate, patient recommendations and patient satisfaction rates were similar in both groups. The laparoscopic anterior repair resulted in an 89% cure or anatomical improvement rate; this compared to 94.2% for the vaginal approach. In the posterior group, laparoscopy resulted in a 94.3% cure or improvement rate compared to 97.5% in the second group. Conclusions: The outcomes of both strategies showed satisfactory results in our study. Consequently, surgeons may choose between the two strategies according to their preference and skill. The two approaches only differed with regard to vaginal scarring. We suggest future research investigating the long-term impact of scarring.

Surgical advancements are focusing currently on minimally invasive techniques, the latest of which is natural orifice transluminal endoscopic surgery. Though this approach is feasible through different natural orifices, the vaginal approach is the one which gained attention the most, given the vaginal flexibility and the ability to access pelvic and abdominal organs. Compared to gynecologists, general surgeons were precedents for using the vaginal orifice as a port of surgical entry. However, this vaginal approach is being more frequently implemented during gynecological surgeries nowadays. Advantages of natural orifice transluminal endoscopic surgery include scarless surgery, better exposure, reduced pain scores, less peri-operative complications, shorter hospital stay and improved patient satisfaction. This article provides an idea on the application of vaginal natural orifice transluminal endoscopic surgery in gynecology along with future potentials.

Total laparoscopic hysterectomy (TLH), is fast replacing the conventional open procedure where and when feasible with greater public awareness and demand. Lesser disastrous major complications and affordability will help towards this trend in making it more popular. Any measures to improve and simplify and speed up this procedure demanding a higher level of skill, should be welcome. A total number of 62 TLH procedures, performed at the Teaching Hospital Peradeniya were followed up for a minimum of 4 months and analysed to see the speed and complications related to the method of vaginal cuff closure.Twenty six (42%) TLH procedures were done entirely trans abdominally with the laparoscope (A), and the rest 36 (58)% had the cuff closed manually, through vaginal approach (V). Complications directly attributable to surgery on the closure of the vaginal cuff itself were much higher with the abdominal technique-6 (23%) instances; but only 3 (8.3%) in the vaginal approach. The average vaginal closure time was over 3 times faster vaginally (19 vs 5.5min) with a lesser complication rate,making it the personal preference of the author as the research progressed explaining the higher proportion of vaginal closures.

We aim to determine the presentation of and immediate and longer-term outcomes of vaginal surgical excision of urethral extrusion of mid-urethral tape (MUT). We performed a retrospective analysis of all patients with urethral extrusion of MUT having vaginal surgical excision between 2007 and 2018. The MUT was removed either partially (via vaginal approach) or completely (via combined vaginal and laparoscopic approach). Functional outcomes and any re-interventions are described. Thirty-four patients of median age 53 (range 34–82) years were identified. Preoperative symptomatic recurrent/persistent urinary incontinence was present in 29/34(85%) with 24/34(71%) women having recurrent/persistent stress urinary incontinence (SUI) or stress predominant mixed urinary incontinence (s-MUI) on urodynamics. Vaginal surgical excision was performed alone in 33/34(97%) women and in combination with laparoscopic removal of abdominopelvic MUT in 1/34(3%) woman. In the longer term vaginal/urethral pain resolved or improved in all 15/15(100%) patients presenting with this complaint whilst patient reported poor flow resolved in 8/9 (89%) women. Twenty-eight of 34 women (82%) had persistent/recurrent SUI or s-MUI following MUT excision. Twenty-four of 34 women (71%) had further SUI surgery with cure or improvement of SUI in 20/24 (83%) patients. The outcome of vaginal surgical excision of the MUT was cure or improvement of pain in 100% and resolution of poor flow in 89% women. Recurrent/persistent SUI or s-MUI was present in 82% following removal as compared to 71% women prior to removal. Of the 71% of women electing to have further surgery for recurrent/persistent SUI/s-MUI, 83% were dry or improved afterwards.

Pelvic organ prolapse affects one in three women, and cystocele accounts for 80% of the indications for surgery. Following the withdrawal of transvaginal mesh from the market, the objective of the present before-and-after study was to compare of the previous reference technique (UpholdTM (Boston Scientific, Marlborough, MA, USA) mesh insertion) with anterior sacrospinous ligament fixation with suturing in terms of the outcomes 2 months after surgery. We performed a retrospective, observational, before-and-after study at Lille University Medical Center (Lille, France) by including consecutive patients operated on between 2011 and 2018 for UpholdTM mesh insertion and between 2018 to 2020 for anterior sacrospinous ligament fixation. The primary outcome was the early recurrence of prolapse, and the secondary outcomes were the occurrence of early per-operative or post-operative complications and the development of de novo stress urinary incontinence. Here, 466 patients were included in the study (382 in the UpholdTM group and 84 in the anterior sacrospinous ligament fixation group). The failure rate at 2 months was 6.0% (5 out of 84) for anterior sacrospinous ligament fixation and 1.3% (5 out of 382) for UpholdTM (p < 0.01). The prevalence of acute urinary retention was significantly lower in the anterior sacrospinous ligament fixation group (3.6%) than in the UpholdTM group (14.1%; p < 0.01), as was the de novo stress urinary incontinence rate (11.9% vs. 33.8%, respectively; p < 0.01). Anterior sacrospinous ligament fixation appears to be an effective, safe alternative to mesh insertion in the management of cystocele via the vaginal approach; the early complication rate was slightly lower, but the early failure rate was slightly higher.

This study was designed to evaluate the modified Goetz-one-stage repair technique for reconstruction of third-degree perineal lacerations (TDPLs) in female camels. Fifteen female dromedary camels with TDPL were surgically reconstructed using the modified Goetz one-stage repair using the three-line closure technique. The surgical outcomes, the interval between repair and breeding, and the postoperative conception of the operated female camels were recorded and analyzed. During the 12-month postoperative follow-up period, TDPLs in 14 female camels (93.33%) healed completely by the first intention with mild inflammatory edema and infection in 2 female camels. One camel (6.67%) had a rectovaginal fistula, which was successfully repaired with suturing through the vaginal approach. Of the 15 female camels, 13 (86.67%) subsequently became pregnant through natural mating within 3 to 6 months postoperatively; however, 2 (13.33%) were one was immature and the other was barren which referred for gynecological treatment. The modified Goetz one-stage repair technique was successful in 14 of the 15 female camels after a single surgery, with a low incidence of postoperative complications. This technique is efficient for the repair of TDPLs in female camels, with promising results for subsequent fertility.

Purpose To present surgical methods and outcomes in women with bladder cancer (BCa) requiring correction of neobladder-vaginal fistula (NVF) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB). Materials and methods The medical records of 163 women who underwent RC with IONB for BCa between January 2010 and December 2018 were retrospectively reviewed. The presence of NVF was confirmed by cystoscopy and/or voiding cystography. NVF repair was performed using a transvaginal approach, which included circumferential incision of the fistula tract, creation of a plane between the neobladder serosa and the vaginal epithelium, and multi-layered transvaginal closure. Results During a median follow-up of 47.9 months, NVF was identified in 12 (8.8%) of the 163 included women. Eight (66.7%) fistulas were located in the proximal anterior vaginal wall and four (33.3%) in the vaginal apex. Median time from RC to NVF repair was 3.4 months (range, 2.1-5.6 months), median NVF size was 6.0 mm (range, 4.0-22.0 mm), and median duration of urethral Foley catheter indwelling was 24.0 days (range, 15.0-43.0 days). Initial repair of NVF was successful in ten (83.3%) patients. Two (16.7%) patients who relapsed retained IONB through the subsequent operation. Two (16.7%) patients developed severe urinary incontinence after NVF repair, requiring anti-incontinence surgery with a synthetic transobturator mid-urethral sling. Conclusion The transvaginal approach for NVF repair is feasible, yielding successful surgical outcomes. However, women should be counseled about the risks of relapse and urinary incontinence.

Introduction: Currently, problems such as constipation due to outlet obstruction, rectal/vaginal prolapse and fecal and urinary incontinence have become increasingly more frequent because of the population aging process, with great impact on the quality of life. Objective: To describe a technique for surgical repair of middle/posterior pelvic floor compartments and extra-mucosal rectal wall treatment by transperineal and vaginal approach, using native tissues and present the results in twenty patients submitted to this surgical technique. Method: Patients with symptoms secondary to middle/posterior pelvic floor descent and anatomical changes confirmed by proctological exam and pelvic MRI defecography. Results were evaluated through the Agachan constipation score, using pre- and post-operative questionnaires. Results: Immediate repair of rectocele and musculature, with prompt improvement of constipation, sustained by 42 months. There were no severe complications in the postoperative period. Conclusion: This is an effective technique, with adequate anatomic repair, improvement of constipation scores and with low risk. RESUMO Introdução: Problemas como constipação intestinal por obstrução de saída, prolapsos retal/vaginal e incontinências fecal e urinária são cada vez mais frequentes pelo envelhecimento populacional, com grande impacto na qualidade de vida. Objetivo: Descrever técnica para correção do compartimento médio/posterior do assoalho pélvico e tratamento extramucoso da parede retal, por vias perineal e vaginal, utilizando tecidos nativos. Apresentar os resultados da cirurgia em 20 pacientes submetidas à técnica. Método: Pacientes com sintomas secundários ao descenso de assoalho pélvico médio/posterior, submetidas à propedêutica – exame proctológico e defecografia por RNM de pelve que confirmaram as alterações anatômicas. A avaliação dos resultados foi feita com questionários no pré e pós-operatório, com a utilização do escore de Agachan para constipação intestinal. Resultado: Correção imediata da retocele e da musculatura, com melhora imediata da constipação intestinal, sustentada ao longo de 42 meses. Sem complicações graves no pós-operatório. Conclusão: Técnica eficaz, com correção anatômica adequada, associada a melhora significativa dos escores de constipação e de baixo risco.

A review of current literature on the results of surgical treatment of patients with pelvic organ prolapse by vaginal approach is presented in the article. The relevant issues are the safety and efficiency of using mesh implants for the surgical correction of pelvic organ prolapse. Most experts recognize a need for further improvement of vaginal reconstruction techniques using synthetic meshes, however, current restrictions in a number of countries significantly impact on the respective studies. Despite the many scientific works and various publications, to date there is no single concept of the pelvic organ prolapse. It is necessary to conduct multicenter clinical studies in order to further develop clinical guidelines and to determine a place of these operations in the surgical treatment of pelvic organ prolapse.

Pelvic organ prolapse (POP) presents a common benign condition in women associated with reduced quality of life (QoL). The use of pessaries is considered a first-line treatment of POP. However, pessaries can cause perforations into adjacent organs resulting in fistulas. We present a series of three cases of rectovaginal fistulas (RVF) due to pessary perforation. Three consecutive cases of pessary-induced RVF in patients with POP stage IV were assessed between September 2016 and September 2019. Consensus for therapeutic strategy was reached by an interdisciplinary board. The RVF were located in the posterior vaginal wall and had a diameter of up to 60 mm. In one of three patients, a two-step approach was chosen with the ostomy being performed at the same time as fistula closure and modified LeFort colpocleisis. It was followed by ostomy closure 3 months later. In two patients, a three-step approach was chosen with the ostomy performed separately due to a local tissue inflammation around RVF. Neither fistula nor POP recurrences have occurred so far. Combined temporary gastrointestinal diversion, RVF closure and POP therapy can be performed as a two- or three-stage approach. Lack of evidence and standardized algorithms in RVF therapy make further clinical studies essential. We encourage the preoperative assessment of any case of complex rectovaginal fistula by an interdisciplinary board for determining an individualized treatment.

INTRODUCTION AND HYPOTHESIS: The practice of same-day surgery among urogynecologic surgeons is increasing worldwide, but the percentage fluctuates among nations. Our primary aim was to investigate the feasibility of same-day surgery for pelvic organ prolapse (POP) using native tissue repair and the reasons why same-day surgery was not possible. Secondarily, we aimed to investigate the cause of hospital contact within 30 days post surgery.METHODS: This is a case-control study including 803 women who underwent POP surgery performed by vaginal approach intended as same-day surgery during a 3-year period. No patients were excluded. Patients were divided into two groups: successful same-day surgery (SDSS) and same-day surgery failure (SDSF).RESULTS: Same-day surgery was performed successfully in 90.7% of the cases. Postoperative complications were the main cause of SDSF (76.0%), and most were caused by voiding dysfunction (VD) (42.7%). Patients receiving surgery in the apical compartment and/or surgery involving two compartments, receiving general anesthesia or having comorbidities equivalent to ASA score 3 had a greater tendency not to be able to complete same-day surgery. Regarding telephone contact with the hospital, the SDSS group was significantly less likely to call compared to the SDSF group (11.3% versus 26.7%) (p CONCLUSIONS: This study demonstrates that same-day surgery for POP has high feasibility and is safe. Complications, hospitalizations and reoperations immediately after surgery and within 30 days were found to be minimal.

Objective: To evaluate the rates of serious complications and reoperation for recurrence following sacrospinous ligament fixation (SSLF) for apical pelvic organ prolapse. Methods: This was a national registry ancillary cohort comparative study. The VIGI-MESH registry includes data from 24 French health centers prospectively collected between May 2017 and September 2021. Time to occurrence of a serious complication or reoperation for genital prolapse recurrence was explored using the Kaplan–Meier curve and Log-rank test. The inverse probability of treatment weighting, based on propensity scores, was used to adjust for between-group differences. Results: A total of 1359 women were included and four surgical groups were analyzed: Anterior SSLF with mesh (n = 566), Anterior SSLF with native tissue (n = 331), Posterior SSLF with mesh (n = 57), and Posterior SSLF with native tissue (n = 405). Clavien–Dindo Grade III complications or higher were reported in 34 (2.5%) cases, with no statistically significant differences between the groups. Pelvic organ prolapse recurrence requiring re-operation was reported in 44 (3.2%) women, this was higher following posterior compared with anterior SSLF (p = 0.0034). Conclusions: According to this large database ancillary study, sacrospinous ligament fixation is an effective and safe surgical treatment for apical prolapse. The different surgical approaches (anterior/posterior and with/without mesh) have comparable safety profiles. However, the anterior approach and the use of mesh were associated with a lower risk of reoperation for recurrence compared with the posterior approach and the use of native tissue, respectively.

Resumen La cicatriz uterina es un defecto en la pared anterior del miometrio secundario a la cesárea. Su prevalencia es muy variable, llegando hasta el 84% en algunos estudios, y aumenta según el número de cesáreas previas. La mayoría de las pacientes pueden ser asintomáticas, pero cuando se manifiesta es principalmente con hemorragia uterina anormal. El manejo de esta patología se ha descrito mediante técnicas farmacológicas y quirúrgicas, siendo más estudiadas las técnicas quirúrgicas, dentro de las que se encuentran la histeroscopía, laparoscopia, laparoscopia asistida con histeroscopía, laparotomía y el abordaje vaginal. Se realizó una revisión en PubMed-MEDLINE y LILACS respecto al manejo de este defecto, tomándose artículos publicados en los últimos cinco años, en la cual se encontraron 37 artículos. El manejo depende principalmente de factores como la sintomatología de la paciente, si tiene paridad satisfecha o no, la profundidad del defecto y las preferencias de la paciente. MÉD.UIS.2019;32(3):11-7 Abstract The postcesarean scar defect is a defect in the anterior wall of the myometrium secondary to the cesarean section. Its prevalence is variable, reaching up to 84% in some studies, increasing with the number of previous cesarean sections. Most of the patients can be asymptomatic, but when it manifests, is mostly with abnormal uterine bleeding. Its management has been described with pharmacological and surgical techniques, the latter being the most researched. They include the hysteroscopy, laparoscopy, laparotomy, and the vaginal approach. A revision in PubMed-MEDLINE and LILACS about the management of this defect was done, including articles published in the last five years, resulting in 37 articles. The selection of the treatment depends on different factors such as the patient’s symptoms, if she has satisfied parity or not, the depth of the defect and the patient’s preferences. MÉD.UIS.2019;32(3):11-7

Objective This study describes the observed trends in hysterectomy routes at Langley Memorial Hospital (LMH) in Langley, British Columbia, over 5 consecutive years. Associations between patient characteristics and surgical approach were explored, and approach-based surgical outcomes were evaluated using the institutional technicity index (TI), defined as the ratio of hysterectomies performed by minimally invasive surgery to all hysterectomies. Methods A retrospective descriptive study involving 706 women who underwent hysterectomy at LMH between January 1, 2012 and December 31, 2016 by six full-time surgeons was performed. From the patient characteristics and surgical outcomes associated with the route of hysterectomy, the annual institutional and overall rates of hysterectomy by type were calculated according to the Canadian Task Force Classification II-2. Results The TI increased from 67% to 92% from 2012 to 2016. Specifically, the proportion of hysterectomies completed by a total laparoscopic approach increased from 37% to 78%, whereas hysterectomies performed by the abdominal or laparoscopic-assisted vaginal approach decreased from 32% to 8% and from 17% to 1%, respectively. Vaginal hysterectomy rates remained constant across the study period. Minimally invasive surgery was associated with significantly reduced surgical blood loss and decreased length of hospital stay, with no difference in surgical time compared with an open approach. Conclusions As far as the study investigators are aware, the TI at LMH is among the highest reported to date in Canada. Potential contributing factors include well-trained and experienced gynaecologic surgeons, readily available peer-to-peer mentorship, certified gynaecologic assistance, dedicated surgical staff, and consistency in the operating room set-up. Hence, achieving a high TI in a community setting is feasible without increasing the risk of surgical complications or length of surgery.

Introduction: The aim of this study is to determine the outcome of surgically treated vesico-vaginal fistulae (VVaFs) using a transvaginal approach with a Latzko technique. Methods: A retrospective chart study was conducted at the Department of Urology, Radboud University Medical Centre. Surgical approaches to repair VVaF, from 2014 to September 2020, were selected. Patients who underwent a transvaginal approach were included. The primary objective was fistula closure. Secondary objectives were predictive factors for the outcome of the surgical procedure, for example, patient characteristics, leakage on cystography 2 weeks postoperative, and surgery time. Results: Thirty-one patients had surgery for VVaF. Twenty-five procedures (81%) were performed transvaginally. Thirteen of these (52%) had successful transvaginal closure after the first attempt. Seven out of 12 had their second attempt at the time of analysis, of which 4 (57%) were successfully closed thereafter. After either 1 or 2 attempts with the transvaginal approach, 17 (68%) of the VVaFs were successfully closed, but 79% if patients who did not yet had a second attempt were taken into account with the current success extrapolated. Only few minor complications were observed. Conclusion: Transvaginal closure of VVaFs with a Latzko technique is successful in about 79% in either 1 or 2 attempts, with few minor complications. A second attempt in closing the fistula with a transvaginal approach is useful, and a previous transvaginal attempt is not a contraindication for a second transvaginal attempt in closing the VVaF surgically.

Objective: Treatment for pelvic organ prolapse (POP) can be surgical. The vaginal approach is a shorter procedure than the abdominal approach, with quicker resumption of activity for the p...

Objective: Genital prolapse is a common pathology in elderly multiparous women. Management is based on fascial or prosthetic plasty. Surgical procedures are multiple and the judgment crite...

Study Objective To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape. Design Demonstration video. Setting Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1] . Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3] . Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation ( Fig. 1 ). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra ( Fig. 2 ). Interventions (1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] ( Fig. 3 ). Conclusion Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.

In hysterectomized patients, even though there is still controversy, evidence indicates that in the short term, the vaginal approach shows benefits over the laparoscopic approach, as it is less invasive, faster and less costly. However, the quality of sexual life has not been systematically reviewed in terms of the approach adopted. Through a systematic review, we analyzed (CRD42020158465 in PROSPERO) the impact of hysterectomy on sexual quality and whether there are differences according to the surgical procedure (abdominal or vaginal) for noncancer patients. MEDLINE (through PubMed), Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and Scopus were reviewed to find randomized clinical trials assessing sexuality in noncancer patients undergoing total hysterectomy, comparing vaginal and abdominal (laparoscopic and/or open) surgery. Three studies that assessed the issue under study were finally included. Two of these had a low risk of bias (Cochrane risk of bias tool), one was unclear. There was significant variability in how sexuality was measured, with no differences between the two approaches considered in the review. In conclusion, no evidence was found to support one procedure (abdominal or vaginal) over another for non-oncological hysterectomized patients regarding benefits in terms of sexuality.

Vesico-vaginal fistula (VVF) is a global healthcare problem that has a high prevalence in developing countries. The aim of this work is to study the epidemiological, clinical and therapeutic characteristics of VVF post-obstetric and gynecologic procedures in order to identify the predictive factors of surgical treatment failure.Data were collected from 132 VVF patients in our institution between 1985 and 2017. VVF was classified according to Zmerli's classification. Patients underwent surgical treatment and were evaluated after a follow-up period of 6 months. Successful treatment was defined as the absence of urine leakage whereas recurrence was defined as the presence of urine leakage immediately after the surgery or after a period of dryness with a confirmed VVF. Risk factors of surgical treatment failure were identified.The average age of patients was 44 years. The patients were multiparous in 62% of cases. VVF was consecutive to hysterectomy in 62.1% of cases, and after childbirth in 34%. VVF was retro-trigonal in 99 cases (75%) and trigonal in 33 cases (25%). The average size of the fistula was 1cm (0.3-2cm). VVF repair was performed by vaginal approach in 68% of cases and abdominal approach in 32% of cases. Treatment failure was noted in 36 patients (27%). Predictive factors of treatment failure were: vaginal fibrosis (P0.001); trigonal location of the fistula (P0.001); large diameter of the VVF1cm (P0.001); and complex and complicated fistulas (P=0.02).Although Tunisia is a developing country, the main cause of VVF was not obstetrical. Treatment failure, noted in almost one third of cases, was, in our series, correlated with the quality of the vaginal tissue, the size and the location of the fistula, and its complexity.4.

Summary Study objective To assess whether the combined vaginal-laparoscopic route may reduce the risk of postoperative bladder atony, when compared to an exclusively laparoscopic approach, in patients presenting with deeply infiltrating rectovaginal endometriosis with extensive vaginal infiltration. Design Retrospective comparative cohort study using data prospectively recorded in the CIRENDO database. Setting Academic Tertiary Care Centre. Patients One hundred and thirty-two consecutive patients who underwent surgery of rectovaginal endometriosis with vaginal infiltration measuring greater than 3 cm diameter. Interventions Combined vaginal-laparoscopic versus laparoscopic approach. Measurement and main results Sixty-two patients underwent excision of endometriosis via a combined vaginal-laparoscopic approach (study group, or cases), while 71 patients underwent surgery via an exclusively laparoscopic route (controls). Rates of preoperative cyclical voiding difficulty and sensation of incomplete bladder emptying were comparable between the two groups. Preoperative urodynamic assessment was carried out in 18% of cases and 38% of controls, with abnormal results in 27.3% and 11.1% of cases and controls respectively. Early postoperative voiding difficulty (post-void residual > 100 mL) occurred in 14.7% and 24.3% of cases and controls respectively. There was a significant reduction in risk of intermittent self-catheterisation of 13% at time of discharge in the study cases. Three months postoperatively, one case and 6 controls had persistent voiding dysfunction requiring prolonged self-catheterisation. Conclusion The combined vaginal-laparoscopic approach for large rectovaginal endometriotic nodules could reduce the risk of postoperative bladder dysfunction, when compared to an exclusively laparoscopic approach, most likely due to a reduced risk of damage to the pelvic splanchnic nerves at the paravaginal level.

Study Objective TVH is most minimally invasive hysterectomy, but experience with this is decreasing due to lack of training and emphasis on vaginal approach. Yet competence in vaginal surgery allows one to expand their minimally invasive surgical repertoire, including adoption of vNOTES into their practice, vaginal laparoscopic entry into peritoneal cavity in the difficult surgical abdomen, vaginal morcellation after TLH, and drainage of pelvic abscess vaginally. We present 8 years of data showing that the majority of patients presenting to resident clinic at an academic medical center can safely have a resident performed TVH. The benefits of TVH make it vital to expand teaching of this procedure in residency programs and minimally invasive fellowships. Additional objectives: present ideas to incorporate simulation into TVH training and make intraoperative vaginal teaching easier and safer. Design retrospective review of resident hysterectomy experience with a single academic surgeon from 2012-2020. Setting academic medical center, resident teaching clinic. Patients or Participants women needing hysterectomy. Interventions Hysterectomy, with over 95% of cases performed with resident as primary surgeon. Measurements and Main Results -379 hysterectomies: 63% TVH, 31% LAVH/TLH, 8% abdominal. - Demographics of the 231 TVH patients: 29% obese, 23% morbidly obese, 22% with prior C/S, and 4.7% nulliparous - TVH without morcellation: average time 146 mins, uterine weight 170 gm (27-235). - TVH with morcellation: average time 188 mins, average weight 308 gms(55-895). -TVH complications: • Cystotomy 1.3% • Ureteral or bowel injury - 0 • EBL>1000 1.7% • Urgent conversion 1.2% • Return to OR 0.8% • Surgical site infections: 0.8% • Chronic femoral nerve pain: 0.4% Conclusion TVH is safest, least invasive invasive hysterectomy route, even when performed primarily by resident physicians, with low complication rates. Surveys show recent graduates are more likely to perform and prefer TVH over other approaches when they've had more exposure and experience. Support is needed from national organizations and minimally invasive fellowship programs to increase competence among young physicians.

OBJECTIVE Report the progress of the treatment of female stress urinary incontinence (SUI) in Brazil through vaginal and abdominal approaches and the direct costs by hospitalisation, using DATASUS-a public entity of the Strategic and Participative Management Secretary of Health Ministry, with the responsibility of collecting, processing, and disseminating public health information. DESIGN Epidemiological study using the Brazilian Public Health Data Center System (DATASUS). PARTICIPANTS/MATERIALS, SETTING, AND METHODS Data were collected on all hospital admissions associated with treatment from 2008 to 2019 from the DATASUS. We analysed the records of hospitalisations associated with an abdominal or vaginal surgical SUI treatment. RESULTS The total number of procedures for the treatment of female SUI performed from 2008 to 2019 was 84.378, of which 70 238 were vaginal and 14 140 abdominal. There was an overall decrease in the number of SUI procedures in Brazil over the years analysed (F = 52.72; P

Objective To discuss the signs and symptoms of a cesarean section (C-section) scar defect, and to describe the techniques to repair the defect using a vaginal approach. Design A video review of a 32-year-old woman with abnormal bleeding and a C-section scar defect managed surgically by vaginal repair. The patient provided consent for video recording and publication. This surgical report, with no identifying patient data, was exempt from the institutional review board approval. Setting Tertiary care facility. Patient(s) A 32-year-old gravida 2, para 2 woman was seen with prolonged menses, and an 11 × 9 × 5-mm C-section scar defect was seen on transvaginal ultrasound. Intervention(s) The patient opted for the repair of the C-section scar defect using a vaginal approach. Main Outcome Measure(s) Postoperative course. Result(s) The patient had resolution of her prolonged menses, and transvaginal ultrasound showed improvement of her C-section scar defect. Conclusion(s) The vaginal approach is an efficacious way to repair a C-section scar defect, particularly when the defect occurs low at the level of the cervix.

Summary Introduction To review the short-term evolution of stress urinary incontinence (SUI) after Uphold™ LITE mesh implantation for genital prolapse repair. Material and methods Retrospective, descriptive, single centre study of women undergoing genital prolapse surgery with Uphold™ LITE mesh insertion between July 2016 and April 2019. Pre-, peri- and 1-year postoperative follow-up data were collected. Results Thirty-six women were included (mean age: 72 ± 7 years). Most patients (75%) had grade III cystocele and three (8.3%) had recurrent prolapse. Mean operative time was 41 ± 12 min. During surgery, no visceral injury or haemorrhagic complications were noted but there were three intraoperative bladder injuries (8.3%). Twelve patients (33.3%) had preoperative SUI, half of which (n = 6; 50%) responded to prolapse repair. De novo SUI was noted in 6/24 (25%) patients. The risk of having persistent postoperative SUI was 50% in patients with preoperative SUI, and the risk of developing de novo postoperative SUI was 25% in patients without preoperative SUI. Thus, patients with preoperative SUI were twice as likely to have persistent postoperative SUI as those without preoperative SUI (RR = 2.0 [95% CI: 0.8175–4.8928]; P = 0.128). Five patients with de novo SUI and three patients with persistent postoperative SUI were subsequently treated with insertion of a mid-urethral sling (MUS). The other patients improved with physiotherapy. Conclusion Risk of persistent SUI after implantation of an Uphold™ LITE mesh is higher in patients with preoperative SUI. Surgical correction with a MUS can be offered in cases of de novo SUI before or after physiotherapy. Level of evidence 4.

ispartof: FUTURE SCIENCE OA vol:6 issue:7 ispartof: location:England status: published

Vaginal ovarian cystectomy has not gained wide acceptance owing to the potential difficulty in entering the cul-de-sac. We review the current evidence on vaginal approaches to benign ovarian cysts. Outcome measures of interest included time to return to work, patient satisfaction, surgical complications and length of hospital stay. Ten studies were included in this review and involving 525 patients. Vaginal ovarian cystectomy is overall safe and feasible in appropriately selected cases with no evidence of intrapelvic adhesions or endometriosis. These findings will need to be validated in appropriately powered studies, before reliable conclusions can be drawn. Furthermore, we emphasize the importance of ultrasound both preoperatively for case selection optimization and intraoperatively, as a means of guidance during posterior culdotomy., Lay abstract The management of benign ovarian cysts through the vagina (VOC) has not gained wide acceptance by gynecologists worldwide owing to the potential difficulty in accessing the pelvic organs through an incision at the top of the vagina that may cause injury to adjacent structures such as the rectum. This is a review of the literature on the effectiveness of VOC. Various techniques have been described. Overall, VOC is safe and effective in appropriately selected cases. Larger studies will need to be conducted to validate these results. We also emphasize the importance of ultrasound both preoperatively as a tool to select the right patients for VOC as well as during surgery as an adjunct to guide the surgeon.

To present surgical methods and outcomes of neobladder-vaginal fistula (NVF) repair after radical cystectomy (RC) with ileal orthotopic neobladder (IONB). Methods: We retrospectively reviewed 136 women who underwent RC with IONB for bladder cancer between January 2010 and December 2018. The NVF was confirmed by cystoscopy and/or voiding cystography. NVF repair was performed using a transvaginal approach, which included circumferential incision of the fistula tract, creation of a plane between the neobladder serosa and the vaginal epithelium, and multi-layered transvaginal closure. Results: During a median follow-up of 47.9 months, NVF was identified in 12 (8.8%) women. Eight fistulas were located in the proximal anterior vaginal wall and four in the vaginal apex. Median time from RC to NVF repair was 3.4 months. Median NVF size and duration of urethral Foley catheter indwelling was 6.0 mm and 24.0 days, respectively. Initial repair of NVF was successful in ten (83.3%) patients. Two (16.7%) patients who relapsed retained IONB through the subsequent operation. Two (16.7%) patients developed urinary incontinence after NVF repair, requiring anti-incontinence surgery. Conclusions: The transvaginal approach for NVF repair is feasible, yielding successful surgical outcomes. However, women should be counseled about the risks of relapse and urinary incontinence.

Background The aim of this study was to evaluate the effect of vaginal repair in patients with cesarean section diverticulum (CSD) who had one or two previous cesarean sections (CSs). Methods From January 2012 to December 2014, 248 women with CSD underwent vaginal repair surgery in Shanghai First Maternity and Infant Hospital. These included 193 women with one previous cesarean section and 55 women with two previous cesarean sections. Excision and suture of CSD was performed through a vaginal approach. The duration of menstruation, the length, width and depth of the CSD and thickness of the remaining muscular layer (TRM) were evaluated before and after surgery by transvaginal three-dimensional (3D) color Doppler ultrasound. Results A total of 221 (89.11%) women were followed-up for more than 3 months, and 168 (67.74%) women were followed-up for more than 6 months. There were significant differences in the average duration of menstruation (7.77 ± 2.05 and 8.02 ± 2.06 days VS 13.99 ± 3.71 days), the average size of CSD (5.54*9.19*5.60 and 5.75*9.04*6.18 mm VS 7.99*12.43*6.62 mm) and the TRM (7.61 ± 2.52 and 7.60 ± 3.00 mm VS 2.51 ± 1.02 mm) after surgery compared with those figures before surgery. The results of this study reveal that vaginal repair could shorten the duration of menstruation and improve anatomical defects (P P > 0.05). Conclusion In CSD patients, the clinical effectiveness of vaginal repair was equivalent between women with one or two previous cesarean sections.

INTRODUCTION AND OBJECTIVE:Hysteropexy (HP) for treatment of uterine/apical prolapse via a vaginal approach is shown to have equivalent medium-term efficacy compared to traditional vaginal hysterec...

To compare laparoscopic and vaginal approaches to uterosacral ligament vault suspension (USLS) by perioperative data, short-term complications, rates of successful concomitant adnexal surgery and procedural efficacy.Retrospective cohort of USLS procedures performed at the time of hysterectomy at a tertiary care center over a 3-year period. Patient demographics, surgical data, concomitant adnexal procedures and complications were abstracted from a surgical database and compared using parametric or non-parametric tests as appropriate. Validated questionnaires (POPDI-6, UDI-6, PROMIS) were used to collect information on recurrence and long-term complications. Patients were analyzed according to both intention-to-treat analysis based on the intended approach and the completed route of surgery to deal with intraoperative conversions.Two hundred six patients met the criteria for inclusion; 152 underwent vaginal USLS (V-USLS) and 54 laparoscopic USLS (L-USLS). No statistically significant differences in mean case time, postoperative length of stay or perioperative infection were found. While no ureteric obstructions occurred in the L-USLS group, in the V-USLS group 14 (9%) obstructions occurred (p = 0.023). Postoperative urinary retention was higher with V-USLS (31% vs. 15%, p = 0.024). Rates of successfully completed adnexal surgery differed (56% vs. 98%, p 0.001) in favor of L-USLS. Patient-reported symptomatic recurrence of prolapse was higher in the V-USLS group (41% vs. 24%, p = 0.046); despite this, re-treatment did not differ between the groups (0% vs. 7%, p = 0.113).Perioperative case time and complications did not differ between approaches. However, rates of completed adnexal surgery were significantly higher in the laparoscopic group, which could influence surgical decisions concerning approaches to prolapse surgery.

The purpose of the studywas to review available data on various techniques for radical trachelectomy, inclusion criteria, advantages and disadvantages.Material and methods.A systematic literature search was conducted in the electronic databases of Medline, Russian Science Citation Index, and Russian State Library in the interval time between 1997 and 2017.Results.To date, only radical trachelectomy has shown its value regarding both aspects of oncologic and reproductive outcomes in patients with invasive cervical cancer. There are currently 5 approaches to radical trachelectomy: transvaginal approach with laparoscopic pelvic lymphadenectomy, abdominal, laparoscopic, robot-assisted and laparoscopic – vaginal approach. Each technique has its advantages and disadvantages.Conclusion.Over the last years, radical trachelectomy has been recognized as a valuable fertility-preserving option for women of child-bearing age with invasive cervical cancer. Radical trachelectomy should be performed by highly skilled surgeons in specialized clinics.

The purpose of this review is to provide an update on evidence to support primary use of the minimally invasive approach provided by vaginal hysterectomy in benign conditions that meet criteria for removal of the uterus. This paper will also serve to discuss why the vaginal approach to hysterectomy has decreased over the last decade and to provide observations and solutions to this problem. Recent findings continue to support vaginal hysterectomy as the preferred route for hysterectomy as endorsed by position statements by the American College of Obstetrics and Gynecology, the American Association of Gynecologic Laparoscopists, the Society of Gynecologic Surgeons, and in a position statement from the Cochrane Review. Even with this evidence and support from national organizations, the number of endoscopic procedures continues to rise, while vaginal hysterectomy rates drop. Evidence suggests that this may be related to an overall decrease in the number of hysterectomies performed and thus inadequate training and therefore a failure to follow an evidence-based approach to hysterectomy. Changes in training including the increased use of simulation and maximizing exposure to surgical cases for those interested in gynecologic surgical subspecialties by residency tracks are two innovations aimed at improving surgical proficiency. As the least invasive and lowest cost route for hysterectomy, vaginal hysterectomy continues to be replaced by endoscopic methods without scientific evidence. As medicine trends toward incentivized payments, this trend will need to change. In order to increase the percentage of vaginal hysterectomies being performed, training and practice patterns need to change to incorporate alternative learning methods and mentorship. Continued research will need to be done to elucidate the impact of these changes on vaginal hysterectomy rate and proficiency.