Robotically assisted laparoscopic lateral suspension: a step-by-step approach aiming to standardize a novel procedure.

INTRODUCTION AND HYPOTHESIS: The aim of this video is to show a step-by-step approach to robotically assisted laparoscopic lateral suspension for pelvic organ prolapse aiming to standardize this procedure. METHODS: This video shows a robotically assisted laparoscopic approach to a POP-Q stage 3 prolapse with a combined anterior and apical defect. First, the trocars are positioned, with one 8-mm trocar, two lateral trocars 5 cm above the anterior-superior iliac spine, and a 10-mm assistant trocar either paraumbilically or suprapubically. Second, the uterovesical pouch is dissected up to 2 cm above the level of the bladder neck. The mesh is then fixed to the vesicovaginal fascia and to the isthmus uteri. Next, a laparoscopic forceps is inserted retroperitoneally through the lateral trocars and the lateral arms of the mesh are pulled retroperitoneally. The peritoneum of the uterovesical fold is sutured, including round ligament plication. Finally, the lateral arms of the peritoneum are fixed to the peritoneum of the abdominal wall. CONCLUSIONS: Robotically assisted laparoscopic lateral suspension is a safe alternative to laparoscopic and robotically assisted laparoscopic sacropexy and very well suited for uterine-preserving POP surgery. This video contributes to the standardization of this procedure, and we believe our video to be useful in helping urogynecologists to perform this innovative procedure.

Combining Sclerotherapy with CO2 Laser Ablation for the Laparoscopic Management of Large Endometrioma: Advantages and Pitfalls.

STUDY OBJECTIVE: To demonstrate the feasibility of management of large endometrioma laparoscopically. DESIGN: Stepwise demonstration with narrated video footage of the laparoscopic 2-step procedure starting with alcohol sclerotherapy of the large endometrioma followed by CO2 laser ablation and 6-month follow-up. SETTING: The debate surrounding the best approach for the management of large endometriomas has been ongoing. Cystectomy especially when treating large endometriomas has been shown to decrease ovarian reserve proportionally to the endometrioma's size.2,4 This is why 2-step approaches have been considered to preserve the ovarian reserve.1,3 We present the case of a 22-year-old nulliparous woman who has primary severe dysmenorrhea resistant to medical treatment. Magnetic resonance imaging shows uterine adenomyosis and a 10 cm large endometrioma of the left ovary and no signs of deep infiltrative endometriosis. She has a desire for pregnancy in the distant future. INTERVENTION: The first step is the laparoscopic ethanol sclerotherapy. After emptying and rinsing the endometrioma's cavity through a 5 mm suction cannula, it is then filled with ethanol through a 14 French Foley catheter to avoid any overflow.5,6 After a time exposure of 10 minutes, the ethanol is withdrawn and the cavity rinsed (Figure 2). The second step of the surgery is performed 12 weeks later (Figure 3). Using CO2 laser, the untreated portion of the inner wall of the remaining endometrioma is vaporized along with remaining superficial endometriosis lesions (Figure 1). CONCLUSION: Laparoscopy sclerotherapy combined to CO2 laser ablation is a feasible technique for the management of a large endometrioma. Further research is still required to evaluate the benefit of a 2-step surgery approach over standard cystectomy and to understand the long-term effects of ethanol-induced ovarian fibrosis.

The distribution of pelvic organ support defects in women undergoing pelvic organ prolapse surgery and compartment specific risk factors.

INTRODUCTION AND HYPOTHESIS: The objective of our study was to describe the distribution of pelvic organ prolapse (POP) in a population of women undergoing POP reconstructive surgery and to identify compartment-specific risk factors. METHODS: We conducted a retrospective observational study in a cohort of 326 women who underwent POP repair and had a standardized preoperative POP assessment using the Baden-Walker classification. The distribution of POP grade was described for each vaginal compartment. The association between the involvement of each specific compartment and predictors was evaluated with a logistic regression model. RESULTS: The frequency of significant POP (grade ≥ 2) was 79% in the anterior compartment, 49% in the middle/apical compartment and 31% in the posterior compartment. Combined significant anterior and apical defects were present in 25% of women. Increasing age was a significant risk factor for apical defect (between 60 and 70 years OR = 2.4, 95% CI 1.2-4.6; > 70 years OR = 3.4, 95% CI 1.7-6.6). Previous hysterectomy (OR = 2.2, 95% CI 1.0-4.6) was a significant risk factor for posterior defect. CONCLUSIONS: In a population undergoing POP surgery, anterior compartment involvement is the most common and serious defect and can often be associated with an apical defect, especially in older women. In case of previous hysterectomy, the posterior compartment may be weakened. These findings may help surgeons to select the appropriate POP reconstructive surgery, which often should address both anterior and apical defects.

Laparoscopic lateral suspension for anterior and apical prolapse: a prospective cohort with standardized technique.

INTRODUCTION AND HYPOTHESIS: Laparoscopic lateral suspension (LLS) for anterior and apical pelvic organ prolapse (POP) repair is a recent approach. Previous studies used various meshes or sutures. The purpose of this study was to evaluate outcomes of a standardized LLS technique. METHODS: From January 2010 until December 2014, we performed POP repair by LLS with mesh on 88 women with anterior and apical POP ≥ stage 2. We used a polypropylene titanized mesh fixed to the vesico-vaginal fascia with absorbable sutures and treated posterior compartment defect by vaginal approach with native tissue repair if required. Between July 2013 and December 2018, all women were assessed by gynecological examination including the pelvic organ prolapse quantification (POP-Q) system. Subjective outcome was evaluated by the patient global impression of improvement (PGI-I) questionnaire. RESULTS: Seventy-nine women (89.8%) were available for follow-up. The mean duration of follow-up was 3.4 years (SD 1.6). Mean age was 59.6 (SD 11.1) years and mean BMI 25.8 (SD 4.0) kg/m2. Ten patients (12.7%) had previous POP surgery. Fifty-two women (65.8%) required posterior colporraphy for associated posterior defect and 21 (26.6%) had associated urinary incontinence (UI) surgery. There were no perioperative complications. The objective cure rate (no prolapse beyond the hymen and no reoperation for POP recurrence) was 87.3%. The reoperation rate for recurrence was 5.1%. The subjective success rate (PGI ≤ 2) was 96.2%. There were no mesh exposures or extrusions. CONCLUSIONS: This standardized LLS is safe and effective with no mesh complications after 3-year follow-up.

Surgical Training for Bowel Endometriosis: A New Wet-lab Model.

STUDY OBJECTIVE: To demonstrate a new wet-lab model for training in conservative bowel endometriosis surgery (shaving and discoid resection). DESIGN: Video demonstration. MATERIALS AND METHODS: (1) Modeling deep infiltrating endometriosis using cryopreserved porcine rectum. (2) Conservative resection (shaving and discoid resection) using cold scissor and carbon dioxide laser (free beam and fiber). (3) Discoid resection. RESULTS: In this video, we present a new training model for improving the surgical management of bowel endometriosis. After dissection of the serosa and muscular layers, a modified biological glue is injected into the porcine rectum to accurately simulate an infiltrating bowel endometriosis lesion. Once dried, the simulated lesion can be resected using conventional laparoscopic instruments (cold scissors) or using more advanced techniques such as carbon dioxide laser, free beam and fiber (Storz and Lumenis). In case of bowel perforation during resection, this model enables realistic suturing. CONCLUSION: This new and highly realistic model allows the next generation of endometriosis surgeons to acquire adequate training to make bowel surgery safer and more effective.

A cross-sectional study on pelvic floor symptoms in women living with Female Genital Mutilation/Cutting.

BACKGROUND: Female Genital Mutilation/Cutting (FGM/C) concerns over 200 million women and girls worldwide and is associated with obstetric trauma and long-term urogynaecological and psychosexual complications that are often under-investigated and undertreated. The aim of this study was to assess the pelvic floor distress and the impact of pelvic floor and psychosexual symptoms among migrant women with different types of FGM/C. METHODS: This cross-sectional study was conducted between April 2016 and January 2019 at the Division of Gynaecology of the Geneva University Hospitals. The participants were interviewed on socio-demographic and background information, underwent a systematic gynaecological examination to assess the presence and type of FGM/C and eventual Pelvic Organ Prolapse (POP), and completed six validated questionnaires on pelvic floor and psychosexual symptoms (PFDI-20 and PFIQ7 on pelvic floor distress and impact, FISI and WCS on faecal incontinence and constipation, PISQ-IR and FGSIS on sexual function and genital self-image). The participants' scores were compared with scores of uncut women available from the literature. The association between selected variables and higher scores for distress and impact of pelvic floor symptoms was assessed using univariate and multivariable linear regression models. RESULTS: 124 women with a mean age of 31.5 (± 7.5), mostly with a normal BMI, and with no significant POP were included. PFDI-20 and PFIQ-7 mean (± SD) scores were of 49.5 (± 52.0) and 40.7 (± 53.6) respectively. In comparison with the available literature, the participants' scores were lower than those of uncut women with pelvic floor dysfunction but higher than those of uncut women without such disorders. Past violent events other than FGM/C and forced or arranged marriage, age at FGM/C of more than 10, a period of staying in Switzerland of less than 6 months, and nulliparity were significantly associated with higher scores for distress and impact of pelvic floor symptoms, independently of known risk factors such as age, weight, ongoing pregnancy and history of episiotomy. CONCLUSIONS: Women with various types of FGM/C, without POP, can suffer from pelvic floor symptoms responsible for distress and impact on their daily life. TRIAL REGISTRATION: The study protocol was approved by the Swiss Ethics Committee on research involving humans (protocol n°15-224).

[Obstetrical anal sphincter injury†: How to manage the subsequent delivery†?] / Lésion obstétricale du sphincter anal†: comment aborder le prochain accouchement†?

Obstetric anal sphincter injury (OASI) is a complication of vaginal delivery. Its potential consequences are numerous and include anal and/or fecal incontinence, sexual problems and perineal pain, which can be aggravated by future pregnancies and childbirth. One common issue after OASI is the assessment of anorectal function to discuss the delivery modalities during the next pregnancy. This dedicated assessment includes a clinical and paraclinical evaluation, with an ultrasound and/or a manometry. This personalized assessment for each patient with a history of sphincter injury allows for a detailed discussion to decide on the route of delivery in an informed manner.

La lésion obstétricale du sphincter anal (LOSA) survient lors d'un accouchement vaginal. Ses conséquences potentielles sont l'incontinence anale et/ou fécale, les troubles sexuels et les douleurs périnéales, qui peuvent être aggravés par de futures grossesses et accouchements. Un des enjeux après LOSA est l'évaluation de la fonction anorectale dans le but de discuter les modalités d'accouchement lors de(s) prochaine(s) grossesse(s). Elle comprend une évaluation clinique et paraclinique spécialisée, incluant l'échographie et/ou la manométrie. Cette évaluation personnalisée pour chaque patiente avec antécédent de lésion sphinctérienne permet une discussion circonstanciée pour décider de la voie d'accouchement de manière éclairée.

Incidence and risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse by lateral suspension with mesh.

INTRODUCTION AND HYPOTHESIS: The objective of our study was to estimate the incidence and identify the risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse (POP) by lateral suspension with mesh. METHODS: We conducted a nested case-control study among 480 women who underwent POP repair by laparoscopic lateral suspension with mesh from January 2004 to October 2012. Cases (n = 18) were women who showed mesh erosion following the first intervention through December 2014. Controls (n = 133) were women randomly selected from the same cohort who did not have any erosion. RESULTS: The risk of mesh erosion was 3.8 % with a mean follow-up of 82.3 months (range 28.2 - 130.6 months). The main risk factor was the use of a type 3 mesh (macroporous with either multifilamentous or microporous components) rather than a type 1 mesh (macroporous and monofilamentous; adjusted OR 13.0, 95 % CI 1.5 - 110.6; P = 0.02). Risk factors included smoking (adjusted OR 10.4, 95 % CI 2.3 - 46.5; P < 0.01) and posterior mesh placement (adjusted OR 5.1, 95 % CI 1.2 - 21.8 P = 0.03). CONCLUSIONS: The risk of mesh erosion is low and may be further reduced by using the appropriate mesh material, and by identifying specific patient characteristics such as tobacco use. As conventional vaginal surgery is effective for the treatment of the posterior compartment, the use of posterior mesh during laparoscopic pelvic floor repair needs to be questioned.

Urinary incontinence as a marker of higher mortality in patients receiving home care services.

OBJECTIVE: To evaluate urinary incontinence (UI) as a predictor of nursing home admission, hospitalization or death in patients receiving home care services. SUBJECTS AND METHODS: A total of 699 community-dwelling participants receiving home care services in Geneva were evaluated in Autumn 2004 using the Minimal Data Set-Home Care, a validated instrument that includes grading of UI. Data on death, hospitalization and nursing home admission were collected up until June 2007. The impact of UI on time-dependent outcomes was analysed using survival analysis and multivariate regression Cox models to adjust for age, gender, body mass index, cardiac failure, cognitive impairment, delirium, depression, disability, alcohol and tobacco use, self-rated health, faecal incontinence and number of medications. RESULTS: We found that UI was present in 193 participants (27.8%). After adjustment for confounding factors, UI was associated with a longer length of hospital stay: +36.7 days, (95% confidence interval [CI]: 1.2-72.3) and a higher mortality rate (hazard ratio [HR] 1.6; 95% CI: 1.1-2.6). The HR for death was 1.5 (95% CI: 0.9-2.5) for participants complaining of one episode of urinary leakage per week at most, 2.0 (95% CI: 1.2-3.5) for those presenting with two or more episodes per week and 4.2 (95% CI: 2.3-7.7; P for trend: <0.001) for daily UI compared with participants without UI. Institutionalization (HR 1.1; 95% CI: 0.6-2.2) and hospitalization rates (HR 1.0; 95% CI: 0.7-1.3) were not different between patients with or without UI. CONCLUSION: In a cohort of patients receiving home care services, UI was a strong predictor of length of hospital stay and mortality, increasing with UI severity.

Robotically assisted laparoscopic repair of anterior vaginal wall and uterine prolapse by lateral suspension with mesh: initial experience and video.

INTRODUCTION AND HYPOTHESIS: Sacral colpopexy/hysteropexy is a well-established approach to vaginal apex support and was the first technique used to treat pelvic organ prolapse (POP) with robotic assistance. However, dissection at the level of the promontory may be difficult, especially in obese patients, and associated with rare but potential serious morbidity such as life-threatening vascular injury. In an attempt to avoid this risk, we describe a new robotic approach for POP repair with lateral suspension. METHODS: From March 2012 through June 2013, ten patients with symptomatic anterior vaginal wall and uterine prolapse were operated by a single surgeon. The video presents the different steps of robotically assisted laparoscopic repair of POP by lateral suspension with mesh and uterine conservation using da Vinci S or Si system. RESULTS: POP repair was successfully completed in all ten patients without any perioperative or postoperative complication. CONCLUSION: Robotically assisted laparoscopic repair of POP by lateral suspension with mesh is a novel and feasible technique with promising short-term results. It may have several theoretical advantages over sacral colpopexy/hysteropexy and may represent an alternative in cases of difficult dissection of the promontory.

Minimally invasive outpatient hysterectomy for a benign indication: A systematic review.

BACKGROUND: Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety and satisfaction. With the continual rise in health costs since 2000, outpatient surgery could be a line of action to improve financial resource utilisation and a solution for continuing to treat patients during crises such as the coronavirus disease 2019 pandemic. OBJECTIVE: This systematic review provides an overview of the literature on minimally invasive outpatient hysterectomy for benign indications. METHOD: A focused systematic review of the medical literature between 2018 and 2022 on outpatient gynaecological surgery for a benign indication was conducted using the PubMed and Google Scholar search engines. We then narrowed our selection to articles that referred to hysterectomy. Successful same-day discharge (SDD) was defined as the patient's return home on the day of the procedure without an overnight stay. RESULTS: Fifteen articles that focused on minimally invasive surgery were included in this review. Most of the studies (n = 11) were conducted in the United States. Outpatient surgery had a mean success rate of 60 % and a mean readmission rate of 3 %. The main reasons for SDD failure were patient choice, failed voiding, the need for pain management, nausea or vomiting, or both and the late timing of surgery. SDD was not associated with more complications and readmissions compared with inpatient care. The three main attribute predictors of SDD were young age, early timing of surgery and short total operative time. Patient satisfaction with SDD was high in absolute terms and relative to satisfaction with hospitalisation. CONCLUSION: Minimally invasive outpatient hysterectomy for a benign indication is feasible and safe but is associated with a notable risk of failure. To increase the success rate of outpatient management, patients must be well selected and surgery pathways must be planned in advance. The implementation of enhanced recovery protocols may help promote outpatient hysterectomy for a benign indication.

Incidence and risk factors for reoperation of surgically treated urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated stress urinary incontinence (SUI). METHODS: We conducted a nested case-control study among 1,132 women who underwent SUI surgery from January 1988 to June 2007. Cases (n=35) were women who required reoperation for SUI following the first intervention up to December 2008. Controls (n=89) were women randomly selected from the same cohort who did not require reoperation. RESULTS: The cumulative incidence of SUI reoperation was 3.1 % with a mean follow-up of 10.9 years (range 1.7-21.0). The main risk factor was the history of more than one vaginal delivery [adjusted odds ratio (OR) 3.5; 95 % confidence interval (CI) 1.0-12.6]. The use of synthetic midurethral slings was a protective factor compared to other surgical procedures for urinary incontinence (adjusted OR 0.1; 95 % CI 0.0-0.6). CONCLUSIONS: The risk of reoperation after SUI surgery appears to be low and associated with multiple vaginal deliveries. Synthetic slings at index surgery are associated with a lower risk of reoperation.

Laparoscopic repair of vaginal vault prolapse by lateral suspension with mesh.

BACKGROUND: To evaluate the long-term outcomes of laparoscopic lateral suspension using mesh reinforcement for symptomatic posthysterectomy vaginal vault prolapse. MATERIALS AND METHODS: We analyzed in a prospective cohort study all the women treated by laparoscopic lateral suspension with mesh for symptomatic vaginal vault prolapse between January 2004 and September 2010. In this procedure, the mesh is laterally suspended to the abdominal wall, posterior to the anterior superior iliac spine. We performed systematic follow-up examinations at 4 weeks, 6 months and yearly postoperatively. Clinical evaluation of pelvic organ support was assessed by the pelvic organ prolapse quantification (POP-Q) grading system. Main outcome measures were recurrence rate, reoperation rate for symptomatic recurrence or de novo prolapse, mesh erosion rate, reoperation rate for mesh erosion, total reoperation rate. OBSERVATIONS AND RESULTS: Of the 73 patients seen at a mean 17.5 months follow-up, recurrent vaginal vault prolapse was registered in only one woman (success rate of 98.6 %). When considering all vaginal sites, we observed a total of 13 patients with recurrent or de novo prolapse (17.8 %). The non-previously treated posterior compartment was involved in eight cases (new appearance rate of 11 %). Of these 13 women, only 6 were symptomatic, requiring surgical management (reoperation rate for genital prolapse of 8.2 %). Four patients presented with mesh erosion into the vagina (5.5 %). Two required partial vaginal excision of the mesh in the operating room (2.7 %). There were no mesh-related infections. The total reoperation rate was 11 %. CONCLUSION: Laparoscopic lateral suspension with mesh interposition is a safe and effective technique for the treatment of vaginal vault prolapse. This approach represents an alternative procedure to the laparoscopic sacrocolpopexy.

Incidence and risk factors for reoperation of surgically treated pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated pelvic organ prolapse (POP). METHODS: We conducted a nested case-control study among 1,811 women who underwent POP surgery from January 1988 to June 2007. Cases (n = 102) were women who required reoperation for POP following the first intervention through December 2008. Controls (n = 226) were women randomly selected from the same cohort who did not require reoperation. RESULTS: The incidence of POP reoperation was 5.1 per 1,000 women-years. The cumulative incidence was 5.6%. Risk factors included preoperative prolapse in more than two vaginal compartments (adjusted OR 5.2; 95% CI 2.8-9.7), history of surgery for POP and/or urinary incontinence (adjusted OR 3.2; 95% CI 1.5-7.1), and sexual activity (adjusted OR 2.0; 95% CI 1.0-3.7). CONCLUSIONS: The risk of POP reoperation is relatively low and is associated with preexisting weakness of pelvic tissues.

Laparoendoscopic single-site supracervical hysterectomy with endocervical resection.

Laparoendoscopic single-site surgery is an attempt to enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Total laparoscopic hysterectomy through single-port access has been reported. Supracervical hysterectomy is an alternative to total hysterectomy but requires morcellation, which is challenging through a single umbilical incision. Herein we report and illustrate with a video supracervical hysterectomy performed via single-site laparoscopic surgery with transcervical morcellation after endocervical resection.

Role of sonography in the diagnostic workup of ovarian and adnexal masses except in pregnancy and during ovarian stimulation.

The main role of imaging is to provide a description of the appearance, size, and location of adnexal lesions and associated abnormalities. In some circumstances, the aggressive potential of an adnexal lesion may be suggested on the basis of the imaging findings, the age of the patient, and the clinical data.

[Endometriosis: an essential differential diagnosis of chronic pelvic pain]. / Place de l'endométriose dans le diagnostic différentiel des douleurs pelviennes chroniques.

In the context of chronic pelvic pain, endometriosis plays a significant role due to its frequency and its effects on the quality of women's lives. It affects 3-10% of women of reproductive age. The clinical signs are part from chronic pelvic pain, dysmenorrhea, dyspareunia, urinary and digestive symptoms as well as infertility. The clinical signs and symptoms may vary and the clinical examination may be difficult to interpret for a physician who is not familiar with the condition. This explains the fact that it takes more time to make the diagnosis of endometriosis. Delay of diagnosis, multiple consultations and complex surgical procedures implicate physical and psychological suffering for the patient with serious complications. For all these reasons, the differential diagnosis of chronic pelvic pain in women should include endometriosis.

Laparoscopic Lateral Suspension (LLS) for the Treatment of Apical Prolapse: A New Gold Standard?

Nowadays, the gold standard to treat apical pelvic organ prolapse (POP) is laparoscopic sacrocolpopexy (LSCP). However, LSCP is a difficult procedure associated with rare but potentially severe complications. Promontory dissection may expose to potential life-threatening intraoperative vascular injuries, and sacral roots or hypogastric nerve damage. There are also a few case reports of spondylodiscitis with consecutive lumbar vertebra bone erosion. Laparoscopic lateral suspension (LLS) with mesh is an alternative technique for apical POP repair. It lowers perioperative risks by avoiding sacral promontory preparation. Recent studies show similar anatomical and functional outcomes to LSCP, with the advantage of better preserving the vaginal axis. Moreover, LLS is well suited for hysteropexy which is important as an increasing number of women prefer uterine preservation during POP surgery. In this article, we discuss both techniques, and we share our opinion on a novel perspective in the treatment of apical POP with uterine preservation.

Outcomes of robotically assisted laparoscopic lateral suspension (RALLS) with mesh for anterior and apical prolapse.

Abdominal sacral colpopexy/hysteropexy is the gold standard for the treatment of vaginal apex support. However, dissection of the promontory may expose to potentially life-threatening complications. To avoid this risk, laparoscopic lateral suspension with mesh is an alternative. Robotic assistance may be helpful in both techniques. The objective of our study was to evaluate outcomes of robotically assisted laparoscopic lateral suspension (RALLS) with mesh for anterior and apical pelvic organ prolapse (POP). From March 2012 to January 2018, 59 consecutive patients underwent RALLS using titanized polypropylene mesh. Between August 2017 and September 2019, all patients were contacted to assess outcome. We performed a clinical exam and asked them to complete the patient global impression of improvement (PGI-I) questionnaire. Fifty-four patients (91.5%) were available for follow-up. Mean age was 58.5 years (28.8-79.8). There were no perioperative complications. The mean follow-up was 33.6 months (11.2-74.1).The objective cure rate (no prolapse beyond hymen) and the subjective cure rate (PGI-I ≤ 2) were 83.3% and 77.2%, respectively. Five women (9.3%) were reoperated for POP recurrence. There was no erosion. Of the 20 women complaining of stress urinary incontinence (SUI) preoperatively, 12 (60%) were cured without any additional SUI procedure. Only two women (10%) required TVT for persistent grade 2 SUI. Two women (5.9%) developed de novo SUI, but none of them required an operation. RALLS repair for POP with mesh is safe and effective and may represent an alternative to sacral colpopexy/hysteropexy.

Is intracrinology of endometriosis relevant in clinical practice? A systematic review on estrogen metabolism.

Endometriosis is a chronic, multifactorial, estrogen-dependent disease. The abnormal endocrine microenvironment of endometriosis lesions is considered a main feature and multiple enzymatic pathways leading to local increased synthesis of estrogens have been identified. However, the relevance of intracrinology in clinical practice is still lacking. Medline, Embase, Scopus database were systematically searched for studies reporting on local estrogens metabolism of endometriotic lesions. The main enzymatic pathways involved in the intracrinology of endometriosis such as aromatase (CYP19A1), 17ß-hydroxysteroid dehydrogenase (HSD17B) type 1, type 2 and type 5, steroid sulfatase (STS), estrogen sulfotransferase (SULT1E1) were assessed with a critical perspective on their role in disease endocrine phenotyping, drug resistance and as therapeutic targets. Overall, studies heterogeneity and missing clinical data affect the interpretation of the clinical role of these enzymes. Although the use of some drugs such as aromatase inhibitors has been proposed in clinical practice for two decades, their potential clinical value is still under investigation as well as their modality of administration. A closer look at new, more realistic drug targets is provided and discussed. Altered expression of these key enzymes in the lesions have far reaching implication in the development of new drugs aimed at decreasing local estrogenic activity with a minimal effect on gonadal function; however, given the complexity of the evaluation of the expression of the enzymes, multiple aspects still remains to be clarified. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022311329, identifier CRD42022311329.