Postpartum cervical length as a predictor of subsequent preterm birth-novel insights on an old enigma.

BACKGROUND: Preterm birth poses one of the biggest challenge in modern obstetrics. Prediction of preterm birth has previously been based on patient history of preterm birth, short cervical length around midtrimester, and additional maternal risk factors. Little is known about cervical length and physiology during the postpartum period and any associations between postpartum cervical features and subsequent preterm birth. OBJECTIVE: This study aimed to determine the feasibility and utility of postpartum cervical length measurements in prediction of subsequent spontaneous preterm birth. STUDY DESIGN: This was a prospective cohort study in a single tertiary center, conducted during a 5-year period (2017-2021). We evaluated the mean postpartum cervical length in patients after both preterm birth and term deliveries at 4 time periods: 8, 24, and 48 hours, and 6 weeks postpartum, with follow-up in their subsequent pregnancies to evaluate gestational age at delivery. The mean postpartum cervical length in different populations stratified by gestational age at delivery was assessed in phase 1 of the study, and the gestational age at subsequent delivery was assessed in phase 2. RESULTS: A total of 1384 patients participated in phase 1. Mean postpartum cervical length was significantly shorter in the preterm birth (<34 weeks' gestation) group than in the term group at 8 hours (8.4±4.2 vs 22.3±3.5 mm; P<.0001), 24 hours (13.2±3.8 vs 33.2±3.1 mm; P<.0001), and 48 hours (17.9±4.4 vs 40.2±4.2 mm; P<.0001) postpartum. There was no significant difference in mean postpartum cervical length between the preterm birth group and the term group at 8, 24, and 48 hours postpartum. Cervical length was similar between the groups at 6 weeks postpartum. A total of 891 patients participated in phase 2. The area under the curve was higher for preterm birth screening based on a history of a short postpartum cervix alone than for a history of spontaneous preterm birth alone (0.66 [95% confidence interval, 0.63-0.69] vs 0.57 [95% confidence interval, 0.54-0.61]; P<.0001). Combining both a history of spontaneous preterm birth and a short postpartum cervix resulted in additional benefit, with an area under the curve of 0.74 (95% confidence interval, 0.73-0.84; P<.0001). CONCLUSION: Postpartum cervical length measurements may assist in detecting the group of patients at higher risk of subsequent spontaneous preterm birth. It may be beneficial to consider an increased follow-up regimen and earlier interventions in this group to reduce adverse perinatal outcomes.

COVID-19 Quarantine and Sexual Function after First Vaginal Delivery.

OBJECTIVES: Sexual function is an important part of quality of life at all ages. Childbirth brings many changes that may affect sexual function. During COVID-19 global pandemic, nuclear families were forced to stay home. The goal of this study was to evaluate sexual function during the COVID-19 quarantine, in postpartum couples in the first months following their first vaginal childbirth. DESIGN: This is a single-center, prospective study of females following their first vaginal delivery and their male partners. Participants were recruited in the maternity ward after their first delivery at Rambam Medical Center. Both spouses signed a consent form for answering the sexual function questionnaires. PARTICIPANTS: Participants were interviewed by telephone during the last week of the first COVID-19 quarantine, according to Arizona Sexual Experience Scale (ASEX). MAIN OUTCOME MEASURES: pre- and post-quarantine sexual function according to ASEX scores. ASEX is a survey that assesses sexual drive, arousal, vaginal lubrication, the ability to reach orgasm, and satisfaction from orgasm. Responses are scored on a 1-6 Likert scale with a potential range of 5-30, where the highest scores indicate worse sexual function. RESULTS: The participants were 38 women and 29 men. The average time from delivery to the interviews was 182.8 ± 84.7 days; 56% of the spouses were under quarantine. The median baseline total ASEX score was 13 (sexual drive 3, arousal 2.5, vaginal lubrication 2.5, ability to reach orgasm 2, orgasm satisfaction 2) for women and 11 (sexual drive 3, arousal 2, penile erection 1, ability to reach orgasm 2, orgasm satisfaction 2) for men. Sixteen percent of the women and none of the men had a baseline sexual dysfunction (ASEX score >19). Significant differences were not observed in total ASEX scores before and during the quarantine. LIMITATIONS: Sexual function at the end of the quarantine was evaluated prospectively and pre-quarantine sexual function was evaluated retrospectively, with the limitation of recall bias. CONCLUSIONS: COVID-19 quarantine did not seem to have a significant effect on female or male sexual function, three to 9 months after the first vaginal delivery. The current study is the first to describe primiparous postpartum sexual function as median ASEX score.

Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial.

BACKGROUND: Vaginal looseness and decreased sensation during intercourse is prevalent in up to 30%-55% of premenopausal women. The efficacy and safety of CO2 laser have been demonstrated for these indications; however, the effect is temporary, up to 6-12 months. No studies regarding the efficacy and safety of adjuvant laser treatments have been conducted to date. AIM: To evaluate the efficacy and safety of a single maintenance CO2 laser treatment in women with vaginal looseness and a concurrent decline in sexual sensation during intercourse. METHODS: This prospective double-blinded randomized controlled trial included premenopausal women who experienced significant temporary improvement in symptoms following previous treatment with CO2 laser due to the abovementioned indications. Participants were randomized to either a single CO2 laser treatment or a single sham treatment. OUTCOMES: Treatment efficacy evaluated with the female sexual function index (FSFI) and the vaginal health index (VHI). RESULTS: Overall, 119 women were included in the study. Mean VHI and FSFI scores were significantly higher in the study group compared to the control group at three months post-treatment (17.34±1.39 vs 12.86±2.23, P = .023 and 30.93±1.79 vs 25.78±1.87, P = .044, respectively). In the study group, both VHI and FSFI returned to baseline at six months post-treatment. The median rate of sexual intercourse per month was increased in the study group at three months post-treatment (8 vs 4, P = .011), and returned to baseline at six months post-treatment. CLINICAL IMPLICATIONS: Maintenance laser treatment provides a temporary non-surgical alternative for women with vaginal looseness and associated sexual dysfunction, though treatment effect seems to be limited to less than 6 months, requiring additional maintenance sessions. STRENGTHS AND LIMITATIONS: The strengths of the current study include a randomized-sham controlled design. Furthermore, VHI was used as an objective evaluation tool, in addition to the FSFI, and assessment of the rate of sexual intercourse. The homogeneity and the relatively small sample size of the cohort is a limitation, and calls for caution in interpretation of the results, and the use of CO2 laser treatment in different age groups and populations. CONCLUSION: A single maintenance laser treatment in women who previously underwent successful treatment with laser is an effective, well-tolerated, and safe procedure for treating symptoms of vaginal looseness and sexual dysfunction, though effects are temporary. Lauterbach R, Aharoni S, Farago N, et al. Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial. J Sex Med 2022;19:1404-1411.

The efficacy and safety of a single maintenance laser treatment for stress urinary incontinence: a double-blinded randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: To evaluate the efficacy and safety of a single carbon dioxide (CO2) laser maintenance treatment in women previously treated successfully with laser for stress urinary incontinence (SUI), who have demonstrated a decline in treatment effect. METHODS: Women aged 40-70 years who experienced temporary significant improvement in symptoms following CO2 laser treatments for SUI were randomized to either the treatment group or the sham treatment control group. Cough test results, 1-h pad weights and scores on the Urogenital Distress Inventory (UDI6), the International Consultation of Incontinence Questionnaire (ICIQ-UI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were obtained at baseline and 3 and 6 months. RESULTS: Of 183 women screened, 131 were included in the final analysis. Demographic characteristics and baseline measures in the outcome tests were similar between the groups. Statistically significant improvements were demonstrated in the study compared to the control group at 3 months post-treatment in positive cough test (44.4% vs. 79.4%, P = 0.002), mean pad weight test (2.3 g ± 1.3 vs. 5.6 ± 1.1, P < 0.001), mean UDI-6(24.7 ± 12.1 vs. 45.1 ± 13.6 SD, P = 0.004), mean ICIQ-UI (16.5 ± 4.3 vs. 10.3 + 3.8, P = 0.003) and mean PISQ-12 (21.3 ± 6.8 vs. 36.6 ± 7.5, P = 0.003). However, values at 6 months post-treatment were similar to those at baseline. CONCLUSIONS: Our results suggest that a single maintenance laser treatment for reducing symptoms of SUI is transiently effective, well tolerated and safe. This treatment modality provides alternative non-surgical therapy for women with SUI.

Higher risk of hemorrhage and maternal morbidity in vaginal birth after second stage of labor C-section.

PURPOSE: This study evaluated the association between timing and indication for previous cesarean section (C-section) and its association with postpartum risks for adverse maternal outcomes, primarily postpartum hemorrhage (PPH) in vaginal birth after cesarean (VBAC). METHODS: This retrospective case-control study examined women following term vaginal delivery in a university-affiliated medical center between 2008 and 2018. Postpartum complications were compared between women who had their first VBAC and a control group comprised of women who had vaginal delivery without prior C-section. Additional analysis was performed to evaluate the association between the timing of previous C-section and the severity of postpartum adverse outcomes. RESULTS: Of the women meeting the inclusion criteria (n = 2879), 1,455 had VBAC and 1,424 were in the control group. Overall, significant postpartum complications, primarily PPH, were observed in the VBAC group compared to controls. Women who underwent C-section during second-stage of labor experienced higher PPH rates and increased drop in hemoglobin levels compared to women who underwent C-section during the first stage of labor or an elective C-Sect. (4.3 ± 0.9 g/dL vs. 2.8 ± 1.1 g/dL vs. 2.4 ± 0.8, p = 0.033). Concomitant increased need for blood transfusion (8.1% vs. 3.5% vs. 2.9%, respectively, p < 0.0001) and uterine atony (12.6% vs. 6.2% vs. 4.4%, respectively, p = 0.009) were also observed. No significant differences were demonstrated in other postpartum adverse effects evaluated. CONCLUSION: VBAC is associated with higher rates of postpartum complications, primarily PPH. The risk is significantly increased in VBAC following a second stage cesarean section. This data should be taken into consideration in the management of laboring women after C-section.

In Vitro Fertilization Entails a High Prevalence of Erectile and Male Sexual Dysfunction: A Prospective Case-Control Study.

PURPOSE: We evaluated the effect of in vitro fertilization (IVF) on sexual function in men, particularly for erectile dysfunction. MATERIALS AND METHODS: A prospective case-control study at a tertiary medical center. The study group comprised men of infertile couples that required IVF to conceive. The control group comprised men of couples who conceived spontaneously. The effects of IVF on sexual and erectile function were assessed based on the International Index of Erectile Function (IIEF-15) and the Self-Esteem and Relationship (SEAR) questionnaires. Participants were followed up to 1 year postpartum. RESULTS: Compared to the control group (378), for the IVF group (356), mean IIEF-15 scores were significantly lower: prior to pregnancy (31.7±4.5 vs 64.4±7.2, p <0.0001), at mid-pregnancy (37.3±5.1 vs 66.4±5.5, p <0.0001) and up to one year postpartum (42.3±4.9 vs 68.6±4.3, p <0.0001). Compared to the control group, in the IVF group, mean SEAR scores were significantly lower at these 3 respective time points (29.9±6.3 vs 66.5±8.3; 34.1±5.8 vs 66.9±7.2; and 40.9±6.7 vs 67.3±5.6; p <0.0001). At the 3 time points, for the IVF compared to the control group, the median monthly sexual intercourse rate was lower; and both the use of phosphodiesterase-5 inhibitor and psychologist/sexologist care were higher. CONCLUSIONS: The prevalence of erectile dysfunction among men participating in IVF in order to conceive is significantly higher compared to couples that conceived spontaneously, thus leading to an extremely high rate of phosphodiesterase-5 inhibitor use.

The Efficacy and Safety of CO2 Laser Treatment for Sexual Function and Vaginal Laxity Improvement in Pre-Menopausal Women.

BACKGROUND AND OBJECTIVES: Vaginal laxity lacks standardized diagnosis and severity criteria. It is considered as a subjective complaint that reflects decreased sexual satisfaction due to vaginal loosening. Treatment modalities have included physiotherapy and plastic surgery. Recently, laser treatments have also gained popularity as a means of relieving gynecological complaints such as pelvic organ prolapse, stress urinary incontinence, and genitourinary syndrome of menopause. The aim of the current study was to evaluate the efficacy of CO2 laser treatment in women for whom a decrease in sexual sensation during intercourse and vaginal loosening were their primary complaints. STUDY DESIGN/MATERIALS AND METHODS: For this prospective study, women with reported vaginal laxity and decreased sensation during intercourse were recruited from the Sexual Dysfunction Clinic in our health care campus. Each participant received three outpatient treatments with laser therapy, according to the same protocol. Treatment efficacy was assessed by changes in the Vaginal Health Index (VHI) and Female Sexual Function Index (FSFI). RESULTS: Overall, 84 pre-menopause women, with a mean age of 47.7 years, were included in the study. Mean VHI and FSFI were increased significantly at 3 months post-treatment and decreased again at 6 months post-treatment: 11.8 ± 1.6, 13.5 ± 1.1, and 11.8 ± 1.2, respectively, P = 0.013; and 21.3 ± 1.7, 29.9 ± 1.6, and 22.5 ± 1.8, respectively, P = 0.022. The rate of sexual intercourse doubled during the period of maximal treatment effect (P < 0.0001). CONCLUSIONS: CO2 laser treatment has both a statistically and clinically significant effect on participants' complaints and sex-life, which wanes by 6 months post-treatment. Laser therapy seems to be safe in the short term, with no serious adverse events reported in the current study. Further studies are warranted to determine the long-term safety and the efficacy of maintenance laser treatments. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Vaginal Fractional Carbon Dioxide Laser Treatment and Changes in Vaginal Biomechanical Parameters.

BACKGROUND AND OBJECTIVES: Vaginal fractional carbon dioxide (CO2 ) laser treatment has emerged in the past two decades as a non-surgical option for vaginal tightening. Mounting evidence supports the effectiveness and safety of this treatment for female sexual dysfunction. A newly developed vaginal tactile imaging (VTI) technique accurately evaluates the biomechanical parameters of the female pelvic floor and vagina, including tissue elasticity, pelvic support, and pelvic muscle function in high definition. In the current study, we evaluated changes in objective biomechanical parameters using VTI, following vaginal CO2 laser treatment for vaginal tightening and sexual dysfunction. STUDY DESIGN/MATERIALS AND METHODS: We conducted a prospective cohort between June 2018 and January 2020. Inclusion criteria were vaginal looseness, decreased local sensation during sexual intercourse, and sexual dysfunction. All the participants were treated with a vaginal carbon dioxide laser. They underwent a gynecological evaluation based on the Vaginal Health Index (VHI) and sexual function assessment according to the Female Sexual Function Index (FSFI). Vaginal biomechanical parameters were assessed by VTI. Initial evaluations were performed at the pre-treatment consult visit, 1 week prior to the first treatment and at a 6-month post-treatment follow-up visit. RESULTS: Twenty-five women were included in the final analysis. Compared with baseline, the post-treatment mean scores for vaginal elasticity and tightening were higher (54.8 ± 5.2 vs. 41.5 ± 6.3, P = 0.0027 and 1.97 ± 0.25 vs. 1.32 ± 0.31, P = 0.0014, respectively). Post-treatment increases were demonstrated in pelvic muscle contraction strength (25.9 ± 3.5 vs. 16.5 ± 4.2, P = 0.0011) and in reflex pelvic muscle contraction (2.93 ± 0.44 vs. 2.12 ± 0.47, P = 0.0022); the mean FSFI and VHI scores were higher following treatment (28.47 ± 1.73 vs. 21.12 ± 1.58, P = 0.036 and 19.15 ± 1.27 vs. 11.6 ± 0.97, P = 0.0032). CONCLUSIONS: The quantification of vaginal biomechanical parameters using VTI technology offers objective evidence of the beneficial effect of vaginal CO2 laser treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Robotic Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy for Benign Indications.

STUDY OBJECTIVE: The Hominis surgical system is a novel robot-assisted system, designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We presented our experience of the first 30 RvNOTES hysterectomies assessing the feasibility and safety of this technology. DESIGN: A two-center prospective study. SETTING: Academic tertiary referral centers. The ethics committees approved the study in both centers. PATIENTS: Thirty women with benign indication for hysterectomy. INTERVENTION: RvNOTES hysterectomy performed by the Hominis surgical system. MEASUREMENTS AND MAIN RESULTS: The primary outcome of the study was the rate of conversion to open or conventional laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment. A total of 15 women were enrolled at each site. The median age was 59 years (range: 37-79) and the median body mass index was 25.4 kg/m2 (range: 17.6-40.0). Twenty-four women (80%) had comorbidities. All the procedures were completed successfully without conversion to open abdominal, traditional vaginal, or conventional laparoscopic surgery. No intraoperative complications were observed. Median blood loss and procedure duration were 50 mL (range: 20-400) and 57 minutes (range: 24-88), respectively. Postoperative pain was minimal, with a median visual analog scale of 3 (range: 1-5) for the first 24 hours following surgery. The median hospital stay was 3 days (range: 2-8). According to the treating physicians' evaluations, the vaginal cuff was fully healed in all patients at the 6-week postoperative follow-up visit. CONCLUSIONS: This is the first publication of robot-assisted vaginal hysterectomy using the Hominis surgical system. The positive results of this study show this new technology to be a safe and effective tool for vaginal natural orifice transluminal endoscopic surgery, enabling surgeons to operate vaginally with the known advantages of robotic modality.

Raynaud's phenomenon as a presenting manifestation of ovarian cancer: A case report.

Raynaud's phenomenon (RP) is characterized by episodes of vasospasm affecting the hands and feet. Paraneoplastic RP, as a single presenting symptom is rarely seen in cases of ovarian cancer (OC), and thus may lead to misdiagnosis. We present a case of paraneoplastic RP in a patient with high-grade serous OC. A 66-year-old female presented with dyspnea and bilateral peripheral cyanosis involving her fingers. CA125 was elevated (423 U/mL). CT revealed a pleural effusion on the left side, suspicious omental lesions and ascites. Omental biopsy and pleural cytology demonstrated high-grade serous OC. Neoadjuvant chemotherapy (carboplatin/paclitaxel) resulted in objective improvement in finger ischemia and complete regression of vasospastic features. However, the patient's disease was refractory to post-surgical treatment and eventually she deceased of multiple organ failure. To conclude, RP may be a presenting symptom of OC. It is important to determine the underlying disease and develop an effective treatment strategy.

Antenatal betamethasone and the risk of neonatal hypoglycemia: it's all about timing.

INTRODUCTION: Our objective was to evaluate whether there is a relationship between the "time during the day" of maternal betamethasone administration between 24 and 34 weeks' gestation and the risk for neonatal hypoglycemia. MATERIAL AND METHODS: A retrospective study included cases between 2008 and 2018. Eligible cases were pregnant women with singleton pregnancies who received a single course of betamethasone between 24 and 34 weeks' gestation. Each woman was allocated into one of four pre-defined groups based on the time when intramuscular betamethasone was administered. Group 1 (23:00-04:59) represents the lowest daily natural corticosteroids' activity, group 2 (05:00-10:59) represents the peak daily natural corticosteroids' activity, whereas group 3 (11:00-16:59) and group 4 (17:00-22:59) present an intermediate natural state of steady corticosteroids' secretion and activity. The primary outcome of the study was the incidence of neonatal hypoglycemia (glucose level of less than 40 mg/dL). RESULTS: We have identified 868 women who received a single complete course of betamethasone, of which 353 women (40.7%) had a steroid treatment latency to delivery up to 14 days. The incidence of neonatal hypoglycemia was significantly higher in group 2 (39.5%, 30/76, p = 0.0063), compared to group 1, who had the lowest incidence of neonatal hypoglycemia (16.9%, 12/71), and to group 3 and group 4. CONCLUSIONS: The "time during the day" when betamethasone administered is important when considering the risk for neonatal hypoglycemia. The risk was significantly higher when betamethasone was administered during the peak time and significantly lower when administered at the nadir time of maternal endogenous corticosteroid activity.

Robotic laparoendoscopic single-site compared with robotic multi-port sacrocolpopexy for apical compartment prolapse.

BACKGROUND: Sacrocolpopexy is a commonly performed procedure for repair of apical compartment prolapse. A Y-shaped mesh is attached to the prolapsed cervix or vagina and suspended to the anterior longitudinal ligament of the sacrum. In addition to conventional laparoscopic and multi-port robotic routes, the robotic laparoendoscopic single-site approach has emerged as a viable, feasible, and widely applicable minimally invasive approach to sacrocolpopexy. OBJECTIVE: To compare robotic laparoendoscopic single-site with multi-port robotic sacrocolpopexy for women with either utero-vaginal or vaginal apical prolapse. MATERIALS AND METHODS: In this single-center randomized controlled trial, 70 women at Pelvic Organ Prolapse Quantitative stages 2-4 were assigned randomly to undergo sacrocolpopexy by robotic laparoendoscopic single-site or multi-port robotic approaches from August 2017 to November 2018. Of 35 women randomized to each group, 32 underwent sacrocolpopexy. Operating time was the primary outcome of the trial. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first postoperative 24 hours (according to a 0-10 visual analogue scale), need for analgesics, and intraoperative and postoperative adverse events. At 6 weeks and 6 months after surgery, patients underwent a physical examination according to Pelvic Organ Prolapse Quantitative measurements, to assess the anatomical success of the surgery. The Pelvic Floor Distress Inventory-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual-12 questionnaires were administered prior to surgery and at 6-month follow-up. The Patient Scar Assessment Questionnaire and the Activity Assessment Scale were administered at 6 weeks and 6 months after the surgery. Exclusion criteria included contraindication to general anesthesia, a history of prior sacrocolpopexy, suspicious adnexal masses, suspicious thickened endometrium, and morbid obesity (body mass index of 40 kg/m2 or more). RESULTS: The mean age of the patients was 58.4 years. More than half of the patients (54%) had stage III prolapse. Mean total operative times were 181.3 ± 32.6 and 157.5 ± 42 minutes for robotic laparoendoscopic single-site and multi-port robotic sacrocolpopexy, respectively; the difference was 23.8 minutes (95% confidence interval, 4.2-43.4, P = .018). The mean differences in duration between the procedures were as follows: 29.8 minutes, 95% confidence interval, 9.2-50.4, P = .005 for anesthesia time; 33.1 minutes, 95% confidence interval, 16.5-49.7, P < .0001 for console time; 8.6 minutes, 95% confidence interval, 1.1-16.3, P = .025 for supracervical hysterectomy time; 8.3 minutes, 95% confidence interval, 1.8-14.8, P = 0.03 for mesh suturing and fixation to the promontory; and 4.7 minutes, 95% confidence interval, 1.5-7.7, P = .004 for peritoneum suturing. Statistically significant differences were not observed between the groups in regard to estimated blood loss, intraoperative complications, and demand for analgesics during hospital stay. Quality-of-life parameters were similar. Patients' assessments of their scars were more favorable in the robotic laparoendoscopic single-site group. CONCLUSION: For sacrocolpopexy, the operative time was longer for the robotic laparoendoscopic single-site than for the multi-port robotic approach. Both approaches are feasible, and short-term outcomes, quality-of-life parameters, and anatomic repair are comparable. Our results are generalizable only to the specific robotic platforms used in the study.

Female Sexual Orgasmic Dysfunction and Genital Sensation Deficiency.

INTRODUCTION: Most studies on female sexual dysfunction (FSD), and female sexual orgasmic disorder (FSOD) in particular, have qualitatively examined cultural and educational factors; only few have quantitatively examined physiological factors. AIM: The aim of this study was to compare quantitative sensory testing (QST) between women for whom FSOD was their primary complaint and other women with FSD. METHODS: In this retrospective study of women who visited a sexual dysfunction clinic, the study group comprised women for whom FSOD was their primary complaint, and the control group comprised other women with FSD. Sexual dysfunction was assessed by the Female Sexual Function Index (FSFI). QST was performed with a thermal and vibration Genito-Sensory Analyzer (GSA; Medoc Ltd, Israel) aimed at the clitoral and vaginal areas. MAIN OUTCOME MEASURE: The main outcome was clitoral and vibratory sensory thresholds in accordance with the presence of FSOD. RESULTS: The study group comprised 89 (45%) women, with a mean age of 37.6 ± 1.9 years; and the control group comprised 110 (55%) women, with a mean age of 37.5 ± 11.3 years. Both mean FSFI-FSOD and total FSFI scores were significantly lower in the study group than in the control group (0.97 ± 0.94 vs 1.91 ± 1.3, P < 0.001) and (11.9 ± 3.2 vs 15.6 ± 3.6, P < 0.001), respectively. Mean clitoral vibratory sensory thresholds were higher in the study group than in the control group: 2.02 confidence interval (CI) 1.12-2.64 vs 1.55 CI 1.12-2.41, P < 0.001. No statistically significant difference was found between the groups in vaginal vibratory thresholds: 3.7 CI 2.6-6.6 vs 3.4 CI 1.9-5.4, P = 0.14. CLINICAL IMPLICATIONS: The findings support the role of the clitoris in obtaining sexual orgasm, thus inferring a possible physiologic cause of FSOD in otherwise healthy women, beyond established psychological causes. STRENGTH & LIMITATIONS: Assessments using an objective quantitative measure (QST) and a subjective tool (FSFI) in both the FSOD and control groups are strengths of this study. The retrospective design is a limitation. CONCLUSION: QST showed a direct correlation between vibratory clitoral stimulation and FSOD; Compared with the control group, women with FSOD are relatively insensitive to clitoral stimulation, but not to vaginal stimulation. Gruenwald I, Lauterbach R, Gartman I, et al. Female Sexual Orgasmic Dysfunction and Genital Sensation Deficiency. J Sex Med 2020; 17:273-278.

Laser-Based Devices for Female Genitourinary Indications: Position Statements From the European Society for Sexual Medicine (ESSM).

BACKGROUND: Laser-based technologies have been commercially marketed as "wonder treatments" without a sufficient and adequate body of evidence. In addition, on July 30, 2018, the U.S. Food and Drug Administration issued a warning regarding the safety of the use of laser-based devices for the following indications: vaginal "rejuvenation" or cosmetic vaginal procedures, vaginal conditions and symptoms related to menopause, urinary incontinence, and sexual function. AIM: To perform a thorough review of the available literature regarding laser-based vaginal devices for the treatment of female genitourinary indications and summarize the results in several short statements according to the level of evidence. METHODS: A comprehensive review of the literature regarding laser treatments for gynecological indications was performed based on several databases. Eligible were studies that included at least 15 patients. OUTCOMES: Several aspects, including preclinical data, have been investigated. For each topic covered, data on laser-based devices were analyzed. RESULTS: Despite the high heterogeneity of studies and its limitations, the committee released several statements regarding the use of laser-based devices for genitourinary indications. CLINICAL IMPLICATIONS: Available data in the clinical setting are still poor, and the impact of these technologies on vaginal symptoms and signs has not been clearly established. STRENGTHS & LIMITATIONS: All studies have been evaluated by a panel of experts providing recommendations for clinical practice. CONCLUSION: It is too early in the evolution and research of laser-based devices to make decisive recommendations regarding vaginal treatments. There is grave need to carry out randomized controlled trials with proper design for safety reasons, possible harm, and short-/long-term benefits for the different indications studied.

Radiofrequency-Based Devices for Female Genito-Urinary Indications: Position Statements From the European Society of Sexual Medicine.

INTRODUCTION: Radiofrequency (RF)-based treatment has been introduced as an esthetic alternative treatment for various medical indications without the scientific backup of a satisfactory body of evidence. Furthermore, the United States Food and Drug Administration issued a warning regarding the safety of energy-based technologies for indications such as vaginal "rejuvenation," cosmetic vaginal treatment, vaginal conditions related to menopause, and symptoms of urinary incontinence and sexual function on July 30, 2018. AIM: To perform a thorough review of the existing literature regarding RF-based vaginal devices for the treatment of female genitourinary indications and summarize the evidence available in a few short statements. METHODS: A thorough review of the literature regarding RF treatments for gynecological indications was performed based on several databases. Studies that included at least 15 patients were eligible for analysis. MAIN OUTCOME MEASURE: Efficacy of RF devices for different genitourinary indications. RESULTS: Although a high level of heterogeneity of studies poses a serious challenge, the committee reached a decision on several statements related to the use of RF-based devices for genitourinary indications. CLINICAL IMPLICATIONS: RF-based vaginal treatments have not been studied thoroughly enough in order to establish decisive recommendations regarding their safety and efficacy. STRENGTH & LIMITATIONS: These position statements have been established by a group of experts. The lack of strong evidence makes it difficult to give decisive recommendations. CONCLUSIONS: Further randomized controlled trials with proper methodology and design are required to establish both benefits and possible harm these treatments may have in both short and long term for all the different indications studied. Otero JR, Lauterbach R, Aversa A, et al. Radiofrequency-Based Devices for Female Genito-Urinary Indications: Position Statements From the European Society of Sexual Medicine. J Sex Med 2020;17:393-399.

A Case of Recurrent Vulvar Carcinoma With Cardiac Metastasis: Case Report and Review of the Literature.

A 67-yr-old female patient was diagnosed with squamous cell vulvar carcinoma and treated with a radical vulvectomy and bilateral sentinel lymphadenectomy. Three months after the surgery, the patient presented with local recurrence and underwent surgical excision of the mass, followed by chemotherapy. Eight months later, the patient was admitted due to weakness and pleural effusion. The patient underwent a chest computed tomography and echocardiogram, which revealed a large mass in the right ventricle penetrating into the pericardium and an additional mass residing on the tricuspid valve. She underwent a pericardial biopsy, and the pathology revealed a moderately differentiated squamous cell carcinoma metastasis. The patient was admitted thereafter in the oncological department for additional chemotherapy treatment. Because of a rapid deterioration in the patient's condition, only palliative treatment was given, and the patient died shortly after. Secondary cardiac tumors are very rare and have not been extensively studied in oncology. Therefore, optimal management is not entirely clear. It is extremely rare for vulvar cancer to metastasize to the heart, and only a handful of cases have been reported in the literature.

The safety and efficacy of CO2 laser in the treatment of stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Conservative treatment is recommended as first-line therapy for stress urinary incontinence (SUI). We hypothesized that CO2 laser treatment would demonstrate safety and efficacy for women with SUI. METHODS: A prospective, open-label, cohort study of 33 women (mean age 43 years) referred from a continence clinic after urologist/urogynecologist assessment, with a verified stress urinary incontinence diagnosis based on urodynamic testing. The participants completed three outpatient treatments with laser therapy and were subsequently evaluated at 1, 3 and 6 months. The independent t and chi-square tests were used to assess changes in sanitary pad usage and SUI symptoms. RESULTS: Sanitary pad usage decreased from a median of 12 per day at baseline to 7 at 1-3 months post-treatment (P < 0.0001) and returned to 12 at 6 months post-treatment. Scores on the Urogenital Distress Inventory and the International Consultation of Incontinence Questionnaire decreased (improved) significantly at 1-3 months post-treatment: from 45 ± 2 and 16 ± 4, respectively, to 29.3 ± 14.7 and 8.15 ± 3.1, respectively (P < 0.0001). The scores returned to levels similar to baseline at 6 months after treatment. Participants reported mild and transient side effects, with significant improvement in quality of life. CONCLUSIONS: Laser therapy can be an optional conservative treatment for women who seek minimally invasive non-surgical treatment for the management of SUI. No serious adverse effects were reported though the sample size was not large, a possible limitation of the study. Further large randomized control trials are needed to appraise the efficacy and safety of laser therapy for stress urinary incontinence and to demonstrate the ultimate utility of this modality.

An Efficient Single-session Spatial Skill Trainer for Robot-assisted Surgery: A Randomized Trial.

STUDY OBJECTIVE: To introduce and examine a single session of spatial skill training as an efficient means of improving surgical suturing performance in robot-assisted surgery. DESIGN: A randomized, controlled trial. SETTING: A tertiary university medical center in Israel. PARTICIPANTS: A purposive sample composed of 41 residents with no robotic suturing skills. INTERVENTIONS: A computer-based simulator training of spatial skills. MEASUREMENTS AND MAIN RESULTS: Participants were randomly assigned to training (n = 21: mean age of 34 years [standard deviation (SD) = 1.92]) and control (n = 20: mean age of 32 years [SD = 3.17]) conditions. The training group underwent a session of spatial skills training, whereas the control group engaged in a neutral activity. After 1 participant was lost to the follow-up of the posttraining performance test, data of 40 participants were analyzed. Robotic suturing task performance with the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) was evaluated using the da Vinci Skills Simulator built-in measure of "excess tissue piercing" and an expert rating of "tissue tearing." The mean number of excess tissue piercing after training (but not after the neutral activity) was significantly lower than before training (3.25 [SD = 1.996] vs 6.75 [SD = 3.68], respectively; p <.001), reflecting an improvement of 52% (decreasing the mean number of excess tissue piercing in a single suture by 3.5 excess piercing trials). After the interventions, the extent of tissue tearing was rated lower in the training group (p = .01), and there was no change in the control group (p = .14). CONCLUSION: We showed the efficiency of a training approach that focuses on spatial skills critical in robot-assisted surgery. We showed that surgeons who received a 1 session spatial skill training with a cognitive spatial skill trainer immediately improved the performance of a robotic suturing task compared with surgeons who did not receive such training.

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Hysterectomy Learning Curve: Feasibility in the Hands of Skilled Gynecologists.

BACKGROUND: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring. OBJECTIVES: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes. METHODS: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts. RESULTS: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011). CONCLUSIONS: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Uterosacral Ligament.

STUDY OBJECTIVE: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension. DESIGN: Stepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage. SETTING: An academic tertiary referral center. The ethics committee ruled that approval was not required for this study. PATIENTS: A 53-year-old woman. INTERVENTIONS: vNOTES hysterectomy and apical suspension to the uterosacral ligament. MEASUREMENTS AND MAIN RESULTS: A 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA). CONCLUSION: vNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.