Colposcopy-A Valuable Diagnostic Tool for Pregnant Women With Unexplained Vaginal Bleeding.

OBJECTIVES: We aimed to examine the diagnostic value of colposcopy in a large cohort of pregnant women with unexplained vaginal bleeding during the second or third trimester. MATERIALS AND METHODS: This retrospective study included women who underwent colposcopy due to vaginal bleeding in the second and third trimesters during 2012-2022 at a tertiary care hospital. Demographics, obstetric data, bleeding characteristics, colposcopy results, cervical cytology testing, a sonogram directed at the placenta, and birth details were collected. RESULTS: In total, 364 women were included. The mean maternal age was 29.7 years and the mean gestational age at examination was 30.7 weeks. Vaginal bleeding was mild in 80.8%, moderate in 14.6%, and severe in 4.7%. Only 3.3% had been vaccinated against human papilloma virus and 25.5% underwent a Pap smear study before pregnancy. Colposcopy diagnosed the bleeding source in 83 women (22.8%). The colposcopic examination revealed vaginal bleeding due to contact bleeding from ectropion in 46 (12.6%), a decidual/cervical polyp in 37 (10.2%), acetowhite epithelium in 12 (3.3%), herpes genetalis in 2 (0.5%), and bleeding from vaginal varices in 2 (0.5%). Of those who were recommended a follow-up examination after the postpartum period, only 49.1% completed such.Among women with compared to without postcoital bleeding ( N = 72), the risk of abnormal colposcopic findings was higher (24 [33.3%] vs 54 [19.7%], p = .017) and the rate of abnormal Pap smear was higher (7 [13.2%] vs 7 [3.2%], p = .008). CONCLUSIONS: Colposcopy can be a valuable diagnostic tool for women with unexplained vaginal bleeding in the second or third trimester.

Implementation of French AmbUlatory Cesarean Section (FAUCS): Establishment of a Learning Curve and Short-term Outcomes.

BACKGROUND: The French AmbUlatory Cesarean Section (FAUCS) technique was introduced to the Galilee Medical Center in September 2021. FAUCS was performed electively for interested women who meet the criteria. OBJECTIVES: To evaluate the learning curve of senior surgeons performing FAUCS, the procedure short-term outcomes, and complications. METHODS: This retrospective study included 50 consecutive women who underwent FAUCS from September 2021 until March 2022 at our facility. Preoperative, intraoperative, postoperative, and demographic data were retrieved from patient electronic charts. RESULTS: The mean duration of surgery was 53.26 ± 11.62 minutes. This time decreased as the surgical team's experience increased: from a mean 58.26 ± 12.25 minutes for the first 15 procedures to a mean 51.17 ± 9.73 minutes for subsequent procedures. The mean visual analogue scale score for 24 hours was 1.08 ± 0.84 (on a 10-point scale). The rate of neonatal cord pH < 7.2 was 6%, and there were 11.3% cases of vacuum assisted fetal extraction. In total, 44% of the women were able to mobilize and urinate spontaneously by 4-6 hours. Complications included bladder injury (n=1), endometritis (n=1), and incisional hematoma (n=1). Overall, the maternal satisfaction rate was high; 94% of the women would recommend FAUCS to others. CONCLUSIONS: FAUCS is a feasible procedure with a high satisfaction rate. Following the first 15 procedures performed by one surgical team, the operative time decreased considerably. Further randomized controlled studies are needed to compare this procedure to regular cesarean section and evaluate neonatal outcomes.

Risk factors and prediction of ectopic pregnancy rupture following methotrexate treatment: A retrospective cohort study.

OBJECTIVE: Ectopic pregnancy (EP) rupture after methotrexate (MTX) treatment can have severe consequences. We examined clinical characteristics and beta-hCG trends that may predict EP rupture after MTX treatment. STUDY DESIGN: In this 10-year retrospective study of 277 women with an EP, we compared clinical, sonographic and beta-hCG trends, before and after MTX treatment, between those who did and did not have an EP rupture after MTX treatment. RESULTS: EP rupture was diagnosed in 41 women (15.1%) within 25 days of MTX treatment, and was correlated with higher parity and advanced pregnancy age: 2(0-5) vs. 1(0-6), P = 0.027 and 6.6(4.2-9.8) vs. 6.1(4-9.5), P = 0.045. EP rupture was also correlated with higher beta-hCG levels on days 0, 4 and 7 of MTX treatment: (2063 vs. 920 mIU/ml), (3221 vs. 921 mIU/ml) and (2368 vs. 703 mIU/ml), respectively, P < 0.001, for all. An increase of beta-hCG by>14% during days 0-4 showed a sensitivity of 71.4% CI 95% [55.4%-84.3%] and a specificity of 67.5% CI 95% [61.1%-73.6%] for predicting EP rupture after MTX treatment. Beta-hCG > 910 mIU/ml on day 0 showed a sensitivity of 80.9% CI 95% [66.7%-90.8%] and a specificity of 70.4% CI 95% [64.1%-76.3%] for predicting EP rupture after MTX treatment. A beta-hCG increase by>14% during days 0-4, and a beta-hCG value > 910 mUI/mL on day 0 were associated with increased risks of EP rupture after MTX treatment; the odds ratios were 6.4 and 10.5, respectively. Odds ratios were 8.06 [CI 95% (3.70-17.56)], P < 0.001 for every percent rise in beta-hCG during days 0-4; 1.37 [CI 95% (1.06-1.86)], P = 0.046 for every week change in gestational age; and 1.001 [CI 95% (1.000-1.001)], P < 0.001 for every unit rise in beta-hCG at day 0. CONCLUSION: Beta-hCG > 910 mIU/ml at day 0, a rise in beta-hCG by>14% during days 0-4, and more advanced gestational age were associated with EP rupture after MTX treatment.

Alternative beta-hCG follow-up protocols after single-dose methotrexate therapy for ectopic pregnancy: A retrospective cohort study.

OBJECTIVE: This study assessed the relevance of reductions in beta-hCG levels between days 0 and 4 and between days 0 and 7 after single-dose methotrexate therapy, and the success of the therapy. STUDY DESIGN: A retrospective cohort study of 276 women diagnosed with ectopic pregnancy who received methotrexate as first-line treatment. Demographics, sonographic findings and beta-hCG levels and indexes were compared between women with successful and failed treatment outcomes. RESULTS: The median beta-hCG levels were lower in the success than the failure group on days 0, 4 and 7: 385 (26-9134) vs. 1381 (28-6475), 329 (5-6909) vs. 1680 (32-6496) and 232 (1-4876) vs. 1563 (33-6368), respectively, P < 0.001 for all. The best cut-off for the change in beta-hCG level from day 0 to 4 was a 19% decrease; the sensitivity was 77.0% and specificity 60.0%, positive predictive value (PPV) was 85% CI 95 [78.7.1%-89.9%]. The best cut-off for the change in beta-hCG level from day 0 to 7 was a 10% decrease; the sensitivity was 80.1% and specificity 70.8%, PPV was 90.5% CI 95 [85.1%-94.5%]. CONCLUSIONS: A decrease of 10% in beta-hCG between days 0 and 7 and 19% between days 0 and 4 can be used as a predictor of treatment success in specific cases.

The value of clinical symptoms, the neutrophil-to-lymphocyte ratio, and ultrasonographic features in predicting adnexal torsion: A case-control study.

AIM: Adnexal torsion remains a diagnostic challenge due to the nonspecific symptoms, sonographic features, and laboratory findings. The value of combining clinical, sonographic, and laboratory features is not well established, and controversy continues regarding their value in diagnosis. This study aimed to review sonographic, clinical, and laboratory features and to analyze their value separately and in combination, in managing and diagnosing adnexal torsions. METHODS: The study included 278 women who underwent urgent laparoscopic surgery due to suspected adnexal torsion, according to clinical suspicion, with or without sonographic concordance. Laparoscopy findings confirmed the definitive diagnosis of torsion. Clinical laboratory and sonographic features were compared between those with and without adnexal torsion. RESULTS: Adnexal torsion was confirmed in 110/278 (39.6%) women. In the torsion compared to nontorsion group, proportions were higher of women with acute abdominal pain in the preceding 24 h ([50] 45.5% vs. [35] 20.8%, p < 0.001), with vomiting ([45] 40.9% vs. [24] 14.3%, p < 0.001) and with suspected torsion by transvaginal sonography ([49] 44.5% vs. [23] 13.7%, p < 0.001). A high neutrophil-to-lymphocyte ratio (>3) was identified in 65 (59.1%) of the study group and 60 (35.7%) of the control group (p < 0.001). Combining the latter three findings, the predicted probability of torsion was 58%-85%, depending on the combinations. CONCLUSIONS: A simple predictive model based on combinations of clinical, laboratory, and sonographic findings can contribute to preoperative diagnosis of adnexal torsion, with predicted probability of 85%. Our model may assist clinicians in evaluating women with suspected adnexal torsion, and improve preoperative diagnostic accuracy.

The impact of the COVID-19 pandemic on ectopic pregnancy presentation and treatment: A retrospective cohort study.

OBJECTIVE: We examined ectopic pregnancy (EP) incidence, presentation and management, before and during the COVID-19 pandemic, and following initiation of vaccination against COVID-19. STUDY DESIGN: In a single-center retrospective cohort study, we compared incidence, presentation and management of EP, between 98 women who presented during the pandemic (March 1 2020 to August 31, 2021), and 94 women diagnosed earlier (March 1 2018 to August 31, 2019). Sub-periods before and after introduction of the vaccination were compared. RESULTS: Age and parity were similar between the periods. For the pandemic compared to the earlier period, the median gestational age at EP presentation was higher (6.24 ± 1.25 vs. 5.59 ± 1.24, P<0.001), and the proportions were higher of symptomatic women (42.9% vs. 27.7%, p = 0.035) and urgent laparoscopies (42.9% vs. 24.5%, p = 0.038). In a multivariable linear model, women who presented during the pandemic were more likely to undergo an urgent laparoscopy [OR 2.30, 95%CI (1.20-4.41)], P = 0.012. In urgent surgeries performed during the pandemic compared to the earlier period, the proportion of women with a hemoglobin drop >2 gr/dL was greater (60% vs. 30%, p = 0.024). Statistically significant differences were not found in sonographic or laboratory findings, in rupture or massive hemoperitoneum rates, or in the need for blood transfusion in urgent laparoscopy. Outcomes were similar before and after introduction of vaccinations. CONCLUSION: During the pandemic, and even after the introduction of vaccination, women with EP were more likely to undergo urgent surgery, and blood loss was greater. This is likely due to delayed diagnosis.

A randomized controlled trial of 2 techniques of salpingectomy during cesarean delivery.

BACKGROUND: Total salpingectomy during benign gynecologic surgery is recommended after completion of childbearing to reduce the risk of developing ovarian cancer. OBJECTIVE: This study aimed to assess operating time and complication rates of "traditional" salpingectomy using the "Knot and Cut" technique, compared with bipolar salpingectomy for sterilization at the time of cesarean delivery. STUDY DESIGN: This was a randomized controlled trial. Women undergoing planned cesarean delivery who desired sterilization were randomized to traditional salpingectomy or bipolar salpingectomy. The bipolar salpingectomy was performed using the LigaSure Precise. The primary outcome was the surgical time of the salpingectomy procedure. Secondary outcomes included total cesarean delivery time and associated bleeding parameters. We estimated that 42 patients would provide 80% power and a 2-sided alpha of 0.05 to identify a 10-minute difference in the primary outcome. RESULTS: A total of 26 women were randomized to bipolar salpingectomy and 25 to traditional salpingectomy. Baseline demographic characteristics were similar between the groups. Six procedures were converted from traditional to bipolar salpingectomy, and 2 traditional salpingectomies failed. The surgical time (16.16±9.53 vs 5.19±3.57 minutes; P<.001), estimated blood loss (928.08±414.66 mL vs 677.15±380.42 mL; P=.029), and need for blood transfusion (20% vs 0%; P=.016) were significantly greater in the traditional salpingectomy than in the bipolar salpingectomy group. The cesarean delivery time was similar (88.92±17.87 vs 88.23±19.85 minutes; P=.89). Hospitalization time was significantly longer following traditional salpingectomy than bipolar salpingectomy (5.24±2.27 vs 3.92±2.01 days; P=.034). CONCLUSION: "Traditional" salpingectomy is associated with longer surgical and hospitalization time, and greater blood loss and risk of blood transfusion compared with "bipolar" salpingectomy. In practices in which "bipolar" salpingectomy is available, it should be preferred over alternative methods of salpingectomy.

Changes in diagnostic sensitivity, incidence and presentation of complete and partial hydatidiform mole over the years.

OBJECTIVE: Molar pregnancy is the most common type of gestational trophoblastic disease. Several recent reports have described changes in the clinical representation, the incidence and the diagnostic sensitivity of molar pregnancy. These changes could be due to widespread use of transvaginal ultrasound and beta-hCG testing in the management of routine first-trimester investigations. STUDY DESIGN: This is a retrospective study of 144 women diagnosed with partial or complete mole at a regional medical center during 2007-2020. Incidence, demographics, clinical features and diagnostic sensitivity were compared between 2007 and 2014 and 2015-2020, and attempts were made to understand the bases of the changes between the time periods. RESULTS: Sixty-two moles were diagnosed during 2007-2014 and 82 during 2015-2020. The proportions of complete moles in the respective periods were 65% (40) and 18% (15). From the earlier to the later period, the incidence and proportion of complete moles decreased, and of partial moles, increased. The median gestational age at diagnosis of molar pregnancy was 9.3 weeks. In the later period, women presented less frequently with vaginal bleeding, though this remained the most common presenting symptom. The proportion of women who underwent surgical evacuation of the uterus due to suspected molar pregnancy decreased, as did the proportion of moles that was suspected in ultrasound evaluation (P < 0.001). CONCLUSION: The proportion of complete moles decreased between the periods examined. Gestational age at diagnosis was similar to data from 1994 to 2013. Some typical presenting symptoms of molar pregnancy decreased. However, earlier diagnosis of missed abortion can miss diagnoses of molar pregnancy.

The impact of radiation therapy on vaginal biomechanical properties.

OBJECTIVE: In women with cervical cancer (CC), treatment with radiation causes changes in vaginal biomechanical properties, anatomy and function. The aims of the current study were to objectively assess effects of radiotherapy (RT) on vaginal elasticity, wall mobility and contraction strength; and to evaluate associations of these changes with sexual function. STUDY DESIGN: This prospective cohort study was approved by our Institutional Review Board. Between May 2018 and June 2020, women with CC who were candidates for RT were eligible to participate. Participants underwent vaginal tactile imaging (VTI) evaluation and were asked to fill the Female Sexual Function Index (FSFI) questionnaire at the time of first RT session and at a 6-month post-treatment follow up visit. Women who underwent radical hysterectomy, or had pelvic side-wall, pelvic or distant organ metastasis were not included. RESULTS: A total of 25 women with locally advanced CC were included in the final analysis. The mean age was 39 ± 2.7 years, the mean BMI was 24.8 ± 2.2 kg/m2 and the median parity was 2 (range: 1-5). Following RT, the mean scores for vaginal elasticity and vaginal tightening were significantly lower than at pre-treatment: 11.3 ± 2.5 vs. 28.3 ± 9, P < 0.0001 and 2.6 ± 0.7 vs. 16.7 ± 3, P < 0.0001, respectively. Following RT, significant decreases were demonstrated in vaginal wall mobility and pelvic muscle contraction strength: from 1.77 ± 0.34 to 0.36 ± 0.15, P < 0.0001 and from 2.55 ± 0.48 to 0.52 ± 0.23, P < 0.0001, respectively. Compared to pre-treatment, post-RT vaginal length was significantly shorter (3.30 ± 0.22 vs. 7.64 ± 0.63, P = 0.0023) and sexual intercourse frequency significantly lower: 1 (range 1-2) vs. 2 (range 1-4), P = 0.014). The mean total FSFI score was significantly lower following RT (6.7 ± 1 vs. 14.5 ± 2.7, P < 0.0001). CONCLUSIONS: Women with locally advanced CC who have been treated with RT exhibit persistent vaginal biomechanical changes that compromise sexual activity and result in considerable distress.

Transvaginal Natural Orifice Transluminal Endoscopic Uterosacral Ligament Hysteropexy: An Innovative Approach for Treatment of Uterine Prolapse.

STUDY OBJECTIVE: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH). DESIGN: Stepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board-approved study. SETTING: Academic tertiary referral center. INTERVENTIONS: This video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture. CONCLUSION: vNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.

Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse.

OBJECTIVE: The objective of this study was to compare surgical and short-term postoperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) uterosacral ligament suspension (USLS) surgery. STUDY DESIGN: A retrospective cohort study was conducted on 135 patients who underwent hysterectomy with USLS via CV (n = 70) or via vNOTES (n = 65). Patients' baseline characteristics, surgical characteristics, and surgical outcomes were retrieved. The primary outcome was total operative time. Secondary outcomes include intra- and post-operative complications. RESULTS: Salpingectomy was performed in all vNOTES procedures and in only 27 % of conventional vaginal procedures (p < 0.005). Compared to the conventional vaginal procedures (n = 65), the vNOTES (n = 70) showed lower mean operative time and mean anesthesia time (101.4 ± 22.3 vs 125.5 ± 27.6 min and 141.4 ± 29.6 vs. 174.0 ± 32.9 min, respectively); and slightly longer median hospital stay (3 [range 2-4] vs. 2 [range 2-4] days, p < 0.05). Compared to women who underwent conventional vaginal hysterectomy with USLS, women who underwent vNOTES hysterectomy with USLS had lower incidences of intraoperative complications (6% vs. 18 %, p < 0.05) and intraoperative ureteral obstruction (0% vs. 8%, p < 0.05); and less estimated blood loss (58 ± 68 ml vs. 143 ± 87 ml, p < 0.05). CONCLUSION: vNOTES hysterectomy with USLS is associated with reduced incidence of intraoperative complications, shorter surgical and anesthesia time, and slightly longer hospital stay, compared to the traditional vaginal surgical approach. Post-operative complications during hospital stay were similar and infrequent following the two procedures.

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.

The impact of vaginal hysterectomy and uterosacral ligament suspension on vaginal elasticity and sexual function.

OBJECTIVE: Hysterectomy for benign indications has profound effects on both anatomical and physiological pelvic floor and vaginal properties. Vaginal tactile imaging (VTI) enables the quantification of pelvic floor and vaginal biomechanical properties; this enables objective evaluation of various pelvic floor functions. The purposes of this study were to evaluate via VTI, the changes in vaginal elasticity, mobility and strength, before and after hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and high utero-sacral ligament suspension (USLS); and to assess associations with sexual function. The objective of the current study was to evaluate the effect of these procedures on vaginal elasticity and sexual function. STUDY DESIGN: This prospective cohort study included women who underwent hysterectomy by vNOTES and USLS for the treatment of pelvic organ prolapse (POP). All the women underwent both pre- and postoperative VTI and sexual function evaluation. Vaginal elasticity and wall mobility, and the contraction strength and tone of levator muscles, were measured prior to and 6 months following surgery using VTI. RESULTS: A total of 23 women, mean age 56.5 years, with stage 3-4 POP participated. Vaginal elasticity increased from 27.3 ± 8.8 to 34.8 ± 12 (P < 0.05) and Female Sexual Function Index (FSFI) scores increased from 22.17 ± 1.62 to 28.66 ± 1.51 (P < 0.05). No correlation was observed between these results. A statistically significant decrease in the mobility of the anterior vaginal wall was demonstrated, from 7.98 ± 10.6 to 0.83 ± 7.5 (P < 0.0001). CONCLUSIONS: VTI showed improvements in vaginal elasticity, mobility and FSFI scores following hysterectomy and POP repair performed by vNOTES.

Feasibility and Learning Curve of Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Hysterectomy and Uterosacral Ligament Suspension in Apical Compartment Prolapse.

OBJECTIVE: The aim of this study was to describe our experience with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) uterosacral ligament suspension (USLS) and to evaluate the learning curve of mastering the skills to operate this procedure. METHODS: This is a prospective study of the first 35 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) (n = 26) and Imelda Hospital (Belgium) (n = 9). The primary outcome was surgical time. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first 24 hours postoperative pain, and the need for analgesia, intraoperative, and postoperative adverse events. RESULTS: The median age was 55 years (range, 40-81). The median operative time was 113 minutes (range, 89-233). For the procedures performed at Rambam, total operative time decreased from the first 13 to the following 13: from 149 minutes (range, 89-233 minutes) to 103 (89-170) (<0.001); Pearson correlation demonstrated a moderate negative significant correlation of surgery duration with surgeon experience (rho = -0.445, P < 0.001). The median estimated blood loss was 30 mL (20-200). The median hospital stay was 2 days (1-3). There were no intraoperative adverse events. The median visual analogue scale score for pain assessment during the first 24 hours after surgery was 1 (range, 1-3). CONCLUSIONS: vNOTES USLS is a feasible procedure that showed marked improvement in surgical performance in a short period, as evidenced by the decrease in surgical time and the low rate of minor associated perioperative complications. Outcomes of long-term follow-up should be investigated.

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.

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.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for omentectomy - A case series.

BACKGROUND AND OBJECTIVE: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been applied massively in the gynecological field in recent years. The aim of the current study is to present the surgical technique of vNOTES omentectomy and to evaluate the feasibility of this procedure. METHODS: A case series study of the first 5 vNOTES omentectomy procedures performed for surgical staging of suspicious early stage ovarian cancer, at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium) between November 2018 and August 2019. Sociodemographic and clinical data were retrieved from patients' electronic charts. Primary points of interest included intra-operative bleeding, length of surgery, length of hospitalization, and surgical complications. RESULTS: The median age was 61 years (range 50-72), and the median BMI was 27 kg/m2 (range 23-33). All the operations were carried out to completion through the vaginal GelPOINT, without insertion of an assistant abdominal trocar or conversion to another surgical approach. The median omentectomy time was 45 min (range: 39-52). The median estimated intraoperative blood loss was 150 ml (range: 20-200). The median hospital stay was 2 days (range: 1-3). CONCLUSIONS: vNOTES is a feasible technique for omentectomy in early stage ovarian cancer, with low rates of complications and improved cosmetic results.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for prophylactic bilateral salpingo-oophorectomy.

BACKGROUND: Prophylactic bilateral salpingo-oophorectomy (BSO) is an important option for reducing the risk of developing ovarian and fallopian tube cancers in women with a hereditary ovarian cancer syndrome. Conventional laparoscopy is generally preferable since it is associated with less morbidity compared to laparotomy. Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging surgical approach that offers several advantages over conventional laparoscopy including reduced postoperative pain, low rate of surgical site infections, fast patient recuperation and better cosmetic outcome [1-6]. The objective of this video is to demonstrate a surgical technique for vNOTES BSO. METHODS: This is a Stepwise demonstration of the vNOTES for prophylactic BSO with narrated video footage. The diameter of Alexis is 7 cm and we used the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA). RESULTS: A 52-year-old carrier of BRCA1 mutation. 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 GEL POINT system and vNOTES technique. CONCLUSIONS: vNOTES for prophylactic BSO via a vaginal port is a feasible technique with promising cosmetic results. This technique allows surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids abdominal wall vessels injury associated with the trocar insertion. Currently, as a result of certain technical limitations, such as when performing BSO without a hysterectomy, there has been a tendency to employ the vaginal access less frequently. In this video presentation, we demonstrate the feasibility of laparoscopic BSO via vNOTES whilst leaving the uterus intact.

Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy.

OBJECTIVES: The vaginal surgical approach has not become the standard of care, despite its advantages. The Hominis™ Surgical System is a humanoid shaped robot-assisted system that was designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We aimed to present our experience with the first RvNOTES bilateral salpingo-oophorectomy (BSO) performed by the Hominis system. STUDY DESIGN: A two-center prospective study of BSO by RvNOTES in women with nonmalignant indications conducted between August and December 2018. Women older than 18 years were offered to participate. Exclusion criteria included a history of abdominal malignancy, pelvic or abdominal irradiation, Crohn's disease, pelvic inflammatory disease, severe infections in the lower abdomen, active diverticulitis, deep infiltrating recto-vaginal endometriosis, and an active vaginal infection. The primary outcome of the study was the rate of conversion to open or 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. RESULTS: Eight women aged 50-70 years with BMI of 19-30 kg/m2 were recruited. All the procedures were completed successfully without conversions to open surgery. No intraoperative complications were observed. Median blood loss was 10 mL (range: 10-50). The median duration of the procedure was 45 min (range: 38-91), and decreased over the study period. Surgeons' usability assessment was very favorable, with a median of 5 on a 1-5 scale. The median visual analog scale (VAS) score was 1 (range: 1-3). CONCLUSIONS: This is the first documentation of a surgery performed via the vagina using robotic instrumentation developed for this purpose. The disruptive technology of RvNOTES, with its fast learning curve, will make gynecological surgeries accessible to more women.