VaNoLaH trial: a study protocol-a multinational randomised controlled trial including two identical substudies comparing vaginal versus vNOTES (vaginal natural orifice transluminal surgery) hysterectomy or laparoscopic versus vNOTES hysterectomy.

INTRODUCTION: Hysterectomy is one of the most common surgeries performed in women. Minimally invasive methods are on the rise globally as they have been shown to decrease surgical morbidity compared with abdominal hysterectomy. Hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) is the latest innovation. It combines the vaginal approach and endoscopy via the vagina. Large pragmatic randomised controlled trials (RCTs) are lacking comparing outcomes after vNOTES, vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). METHODS: Multicentre pragmatic RCT aiming to recruit 1000 women aged 18-75 years undergoing hysterectomy for benign disease. The RCT includes two identical substudies (groups A and B). If VH is considered safe and feasible, the patient will be randomised within group A (VH vs vNOTES). If VH is not considered safe or feasible, patients will be randomised within group B (LH vs vNOTES). ANALYSIS: Primary outcome is the proportion of women leaving the hospital within 12 hours after surgery. Secondary outcomes are hospitalisation time, conversion rates, duration of the surgical procedure, intraoperative complications, postoperative complications and readmission. ETHICS AND DISSEMINATION: The Ethical Board Committee at Imelda Hospital, Bonheiden, Belgium, has approved the research protocol 230704 (principal investigator). Before including patients, all centres will require local or national ethical approval. The results of the study will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05971875.

Effect of Vaginal Microecological Alterations on Female Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the correlation between endogenous vaginal microecological alterations and female pelvic organ prolapse (POP). METHODS: Patients who underwent vaginal hysterectomy were retrospectively analyzed as the POP group (n = 30) and the non-POP group (n = 30). The vaginal microbial metabolites and enzyme levels were tested using the dry chemoenzymatic method. The mRNA and protein expression were tested using real-time quantitative PCR and immunohistochemistry. SPSS version 25.0 and GraphPad Prism 8.0 were performed for statistical analysis. RESULTS: Compared with the non-POP group, the vaginal pH, H2O2 positivity and leukocyte esterase positivity were higher in patients with POP (all p < 0.05). Further analysis showed that patients with pelvic organ prolapse quantification (POP-Q) stage IV had higher rates of vaginal pH, H2O2 positivity and leukocyte esterase positivity than those with POP-Q stage III. Additionally, the mRNA expression of decorin (DCN), transforming growth factor beta 1 (TGF-ß1), and matrix metalloproteinase-3 (MMP-3) in uterosacral ligament tissues were higher, whereas collagen I and III were lower. Similarly, the positive expression of MMP-3 in uterosacral ligament tissue was significantly upregulated in the POP group compared with the non-POP group (p = 0.035), whereas collagen I (p = 0.004) and collagen III (p = 0.019) in uterosacral ligament tissue were significantly downregulated in the POP group. Correlation analysis revealed that there was a significant correlation between vaginal microecology and collagen metabolism. In addition, MMP-3 correlated negatively with collagen I and collagen III (p = 0.002, r = -0.533; p = 0.002, r = -0.534 respectively), whereas collagen I correlated positively with collagen III (p = 0.001, r = 0.578). CONCLUSIONS: Vaginal microecological dysbiosis affects the occurrence of female POP, which could be considered a novel therapeutic option.

Colporrhaphies versus Colpocleisis Following Vaginal Hysterectomy for the Treatment of Advanced Pelvic Organ Prolapse: A Comparative Study.

BACKGROUND: Obliterative vaginal procedures may offer lower perioperative morbidity and equal success rates as reconstructive procedures for frail and elderly women who no longer desire future coital function. The combination of vaginal hysterectomy with either reconstructive or obliterative vaginal procedures has not yet been investigated. OBJECTIVES: To compare peri- and postoperative outcomes of vaginal hysterectomy with pelvic floor reconstruction (VHR) vs. vaginal hysterectomy with colpocleisis (VHC). METHODS: We conducted a retrospective study comparing medical and surgical data of patients undergoing either VHR or VHC between 2006 and 2015. Data were obtained from inpatient and outpatient medical records including peri- and postoperative course, as well as long-term (24 months) follow-up data. RESULTS: We identified 172 patients who underwent VHR and 44 who underwent VHC. Patients in the VHC group were significantly older (71.3 ± 4.5 vs. 68.6 ± 6.5 years, P = 0.01), and more likely to have medical co-morbidities (P = 0.001 and P = 0.029, respectively). Patients in the VHC group experienced shorter operative time (2.3 ± 0.58 vs. 2.7 ± 1.02 hours, P = 0.007), lower perioperative blood loss (P < 0.0001), shorter hospital stay (P < 0.0001), and lower rates of postoperative urinary retention. Long-term pelvic organ prolapse (POP) recurrence rates were significantly higher among the VHR group. Postoperative resolution of both stress urinary incontinence and overactive bladder were common in both groups. CONCLUSIONS: VHC is associated with lower perioperative blood loss, shorter operative time, shorter hospital stay, shorter time with an indwelling catheter, and lower long-term objective POP recurrence rates.

Comparison of hysterectomy cases performed by transvaginal natural orifice transluminal endoscopic surgery: A paired sample cross-sectional study.

This study aimed to investigate the feasibility, indications, and benefits of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) hysterectomy for nonmalignant gynecological diseases. The clinical data, including the baseline information and surgical conditions of 81 patients who underwent v-NOTES hysterectomy for nonmalignant gynecological diseases in a tertiary university hospital from October 2018 to August 2022, were retrospectively analyzed and compared with the total laparoscopic hysterectomy group (200 cases) and the transumbilical laparoendoscopic Single Site Surgery group (150 cases). In comparison with the other 2 groups, the highest proportion of patients in the v-NOTES group had cervical intraepithelial neoplasia. Accordingly, mean preoperative uterine volume measured by sonography was significantly smaller in the v-notes group. In the v-NOTES group, the mean number of vaginal deliveries and age were significantly higher, while the mean number of previous abdominal surgeries was lower compared to the other 2 groups. The V-NOTES group had a shorter operation time, shorter postoperative urinary catheter insertion time, earlier intestinal recovery days, shorter hospital stay, and lower visual analogue scale scores after surgery, and the differences were statistically significant. When indicated appropriately, v-NOTES hysterectomy can be a feasible and advantageous surgical modality. In particular, in comparison to the laparoendoscopic Single Site Surgery and total laparoscopic hysterectomy groups, the v-NOTES group had advantages in postoperative recovery and had more aesthetic surgical results.

Comparison of survival outcome of open, total laparoscopic, and laparoscopy-assisted radical vaginal hysterectomy for stage IB2 cervical cancer patients: A multicenter retrospective study.

The aim of this study was to compare survival outcomes of 3 different radical hysterectomy (RH) types, namely total abdominal radical hysterectomy (TARH), total laparoscopic radical hysterectomy (TLRH), and laparoscopy-assisted radical vaginal hysterectomy (LARVH), in patients with FIGO stage IB2 cervical cancer. We retrospectively identified a cohort of patients who underwent RH for cervical cancer between 2010 and 2017. Patients with stage IB2 cervical cancer were included and were classified into TARH, TLRH, and LARVH treatment groups. Survival outcomes were estimated by the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards models were fit to estimate the independent association of RH technique with outcome. 194 patients were included in this study: 79 patients in the TARH group, 55 in the TLRH group, and 60 in the LARVH group. No significant differences were found in clinicopathological characteristics between the 3 RH groups. On comparing survival outcomes with TARH, both TLRH and LARVH showed no significant difference in terms of 5-year overall survival (TARH vs TLRH, P = .121 and TARH vs LARVH, P = .436). Conversely, compared to the TARH group, 5-year progression-free survival (PFS) was significantly worse in the TLRH group (P = .034) but not in the LARVH group (P = .288). Multivariate analysis showed that TLRH surgical approach (hazard ratio, 3.232; 95% confidence interval, 1.238-8.438; P = .017) was an independent prognostic factor for PFS in patients with IB2 cervical cancer. Our study suggests that in patients with FIGO stage IB2 cervical cancer, among the minimally invasive RH approaches, TLRH and LARVH, only TLRH approach was associated with worse PFS when compared with the TARH approach.

Impact of Mannitol Bladder Distension in the Intraoperative Detection of Ureteral Kinking During Pelvic Floor Surgery.

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

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review.

OBJECTIVE: To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. DATA SOURCES: We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. METHODS OF STUDY SELECTION: Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. TABULATION, INTEGRATION, AND RESULTS: The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. CONCLUSION: Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022327490.

Minimally Invasive Sacrohysteropexy Versus Vaginal Hysterectomy With Uterosacral Ligament Suspension for Pelvic Organ Prolapse: A Prospective Randomized Non-Inferiority Trial.

STUDY OBJECTIVE: To investigate whether minimally invasive Sacrohysteropexy (SH) is non-inferior to vaginal hysterectomy (VH) with uterosacral ligament suspension (USLS) in women with symptomatic uterovaginal prolapse. DESIGN: Prospective, randomized, non-inferiority study. SETTING: Tertiary university-based hospital. PATIENTS: A total of 146 patients with uterovaginal prolapse between July 2016 and August 2019. INTERVENTIONS: Patients were randomly assigned in a 1:1 ratio to either laparoscopic or robotic SH surgery or VH with USLS surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was prolapse recurrence at 1 year after surgery, defined as prolapse ≥ stage 2 evaluated using the pelvic organ prolapse quantification system, bothersome vaginal bulge symptoms, or retreatment for prolapse. The secondary outcomes included operation time, estimated blood loss, hospital stay, operation-related complications, pain intensity, quality of life, and activities of daily living. Of 146 women who underwent randomization, 73 in the SH group and 73 in the VH with USLS group were analyzed. SH was non-inferior for recurrence compared with VH with USLS (16.4% vs 15.8%, 95% confidence interval: -13.0% to 14.2%). Operating duration and transvaginal length were significantly longer in the SH group, while there were no significant differences in the estimated blood loss, length of hospital stay, or postoperative complication rates. Although perioperative pain intensity was greater from 1 week to 1 month in the SH group, the quality of life and activities of daily living did not differ between the groups throughout postoperative year 1. CONCLUSION: Laparoscopic or robotic SH was non-inferior to VH with USLS for the recurrence of pelvic organ prolapse at the 1-year follow-up.

Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score.

INTRODUCTION AND HYPOTHESIS: We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model. METHODS: We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic. RESULTS: For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all). CONCLUSIONS: A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Reducing patient's perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT).

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

Central Sensitisation Syndrome: A Frequent Finding in Women with Pelvic Floor Symptoms Without Evident Urogenital Prolapse.

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

Long-term risk of adnexal operation after vaginal hysterectomy for pelvic organs prolapse repair.

OBJECTIVE: To determine if women who undergo vaginal hysterectomy for pelvic floor prolapse repair without concomitant opportunistic bilateral salpingo-oophorectomy are at increased risk of further complications related to the remaining adnexa later in life. STUDY DESIGN: The database of a tertiary university medical center was searched for all women who underwent vaginal hysterectomy as part of the treatment for pelvic organ prolapse, without opportunistic adnexectomy, from 2006 to 2015 to provide adequate time for long-term evaluation. Demographic and clinical data including surgeries performed during the long-term follow-up were collected from all medical insurer electronic medical records. RESULTS: The cohort included 427 women of mean age 63 ± 9.3 years; 90.9 % were postmenopausal. Mean duration of follow-up was 10.7 ± 2.6 years. During the follow-up period, only 3 patients (0.7 %) were re-operated for left adnexal pathology, non-malignant in all cases. CONCLUSION: In women undergoing vaginal hysterectomy for pelvic organ prolapse without opportunistic adnexectomy, preservation of the adnexa poses only a very low risk for adnexal pathology or need for reoperation later in life.

Characteristics Associated With Surgical Failure After Native Tissue Apical Prolapse Repair.

OBJECTIVE: To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair. METHODS: This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosacral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with P <.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model. RESULTS: One hundred eighty-six participants underwent surgery; 183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.86-0.98, P =.016). CONCLUSION: Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT02431897.

Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To determine the utility of routine postoperative vaginal cuff examination for detection of vaginal cuff dehiscence (VCD) after total laparoscopic hysterectomy (TLH). DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: All patients who underwent TLH with a minimally invasive gynecologic surgeon at our institution from 2016 to 2022. INTERVENTIONS: Laparoscopic hysterectomy with routine vaginal cuff check 6 to 8 weeks postoperatively and laparoscopic hysterectomy without routine vaginal cuff check. MEASUREMENTS AND MAIN RESULTS: We identified 703 patients who underwent TLH, 216 (30.7%) with routine cuff checks and 487 (69.3%) without. Within the no cuff check group, 287 (58.9%) had entirely virtual follow-up. There was no difference in VCD between the routine cuff check (1.28%, n = 2) and no cuff check groups (0.93%, n = 7, p = .73). Median time to VCD was 70.0 days (27.5-114.0). No VCDs were identified in asymptomatic patients on routine examination, and both patients in the cuff check group with VCD had appropriately healing cuffs on routine examination. In the cuff check group, 7 patients (3.2%) had findings of incomplete healing requiring intervention (silver nitrate, extended pelvic rest), all of whom were asymptomatic at the time of examination. Eight patients (3.7%) in the routine cuff check group and 21 (4.3%) in the no examination group required a nonroutine cuff check owing to symptoms. There was no difference in points of contact for postoperative symptoms between the groups (median 0 [0-1.0] for both groups, p = .778). CONCLUSION: Routine postoperative vaginal cuff examination does not seem to affect or negate the risk of future VCD. Virtual follow-up for asymptomatic patients may be appropriate after TLH.

Salpingo-Oophorectomy During Non-Descent Vaginal Hysterectomy Using the Paily Vaginal Oophorectomy Clamp.

We conducted a 6-year prospective surgical case series study at a tertiary care centre in South India to evaluate the safety and efficacy of the novel Paily Vaginal Oophorectomy Clamp and its unique application technique during non-descent vaginal hysterectomy requiring salpingo-oophorectomy. The Paily Vaginal Oophorectomy Clamp's reversed blade design allows direct and secure grasping of the infundibulopelvic ligament as there is no intervening tissue near the joint, reducing the risk of slippage. In contrast, while using conventional clamps such as Heaney's, infundibulopelvic slippage occurs due to the presence of tissue between blades near the joint. A demonstration video is provided (Video).

Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study.

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

Comparison of Readmission Rates for Same-Day Versus Next-Day Discharge After Benign Vaginal Hysterectomy.

IMPORTANCE: Same-day discharge (SDD) for laparoscopic hysterectomy is shown to be safe and acceptable, but data for vaginal hysterectomy (VH) are lacking. OBJECTIVE: The aim of this study was to compare 30-day readmission rates, timing, and reasons for readmission for SDD versus next-day discharge (NDD) after VH. STUDY DESIGN: This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Cases of VH with or without prolapse repair were identified by Current Procedural Terminology codes. The primary outcome was 30-day readmissions after SDD versus NDD. Secondary outcomes included reasons for and time to readmission and a subanalysis evaluating 30-day readmissions for those with prolapse repair. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analyses. RESULTS: There were 24,277 women included; 4,073 (16.8%) were SDD. The 30-day readmission rate was low (2.0%; 95% confidence interval [CI], 1.8-2.2%), with no difference in odds of readmission for SDD versus NDD after VH in multivariate analysis (SDD adjusted odds ratio [aOR], 0.9; 95% CI, 0.7-1.2). Results were similar in our subanalysis of VH with prolapse surgery (SDD aOR, 0.94; 95% CI, 0.55-1.62). Median time to readmission was 11 days and did not differ (SDD interquartile range, 5, 16 [range, 0-29] vs NDD, 7, 16 [range, 1-30]; Z = -1.30; P = 0.193). The most common reasons for readmission were bleeding (15.9%), infection (11.6%), bowel obstruction (8.7%), pain (6.8%), and nausea/emesis (6.8%). CONCLUSIONS: Same-day discharge after VH did not have an increased odds of 30-day readmission compared with NDD. This study, with preexisting data, supports the practice of SDD after benign VH in low-risk patients.

Feasibility and safety of a surgical training program in total laparoscopic hysterectomy: Results of a pilot trial.

BACKGROUND: It is widely accepted total laparoscopic hysterectomy (TLH) and vaginal hysterectomy are less invasive procedures compared to total abdominal hysterectomy (TAH). However, rates of TAH remain unreasonably high. AIM: To pilot-test a model of training for practising obstetricians and gynaecologists (O&Gs) in TLH. MATERIALS AND METHODS: Training of participating O&Gs was conducted across four hospitals in Queensland, Australia, while other O&Gs were observed as contemporary controls. Type of hysterectomy, details of the surgery, including adverse events, were collected from hospital medical records. RESULTS: Eleven O&Gs completed the pre-intervention and intervention training periods, and nine completed the post-intervention follow-up. TLH rates increased from 24% prior to 75% during and 68% after intervention. Overall, the uptake rate of TLH showed a two-fold increase during the intervention period (2.08, 95% CI: 1.16-8.56, P < 0.001) and a 12% increase was retained during the follow-up period (1.12, 95% CI: 0.54-4.02, P = 0.427). Pre-intervention, across all sites, 24% of hysterectomies were performed via TAH by the participating specialist trainees, which decreased to 13% during the intervention and 14% during follow-up. The rate of adverse events decreased from 13.5% at pre-intervention, to 6.4% during and 4.2% post-intervention. By comparison, no change in surgical approach or rate of adverse events was observed in the control group. CONCLUSIONS: The implementation of a formal and structured surgical training program teaching TLH resulted in important benefits to trainees, patients and society in the four trial hospitals.

Comparative outcomes between transvaginal endoscopic hysterectomy and total laparoscopic hysterectomy in patients with benign uterine disease: A single-center, retrospective, cohort, interrupted time-series study.

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