Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Deconstructed: Expanding Minimally Invasive Gynecologic Surgeons' Toolbox.

Background: The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods: This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results: The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions: vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).

vNOTES retroperitoneal sentinel lymph node dissection for endometrial cancer staging: First multicenter, prospective case series.

INTRODUCTION: The current standard treatment for endometrial cancer is a laparoscopic hysterectomy with adnexectomies and bilateral sentinel node resection. A retroperitoneal vNOTES sentinel node resection has several theoretical potential advantages. These include being less invasive, leaving no visible scars, operating without Trendelenburg, and therefore offering the anesthetic advantage of easier ventilation in obese patients and following the natural lymph node trajectory from caudally to cranially and therefore a lower risk of missing the sentinel node. The aim of this study is to determine the feasibility of a retroperitoneal vNOTES approach to sentinel lymph node dissection for staging of endometrial cancer. MATERIAL AND METHODS: A prospective multicenter case series was performed in four hospitals. A total of 64 women with early-stage endometrial carcinoma suitable for surgical staging with sentinel lymph node removal were operated via a transvaginal retroperitoneal vNOTES approach. The paravesical space was entered through a vaginal incision after injecting the cervix with indocyanine green. A vNOTES port was placed into this space and insufflation of the retroperitoneum was performed. Sentinel lymph nodes were identified bilaterally using near-infrared light followed by endoscopic removal of these nodes. RESULTS: A total of 64 women with early-stage endometrial cancer underwent sentinel lymph node removal by retroperitoneal vNOTES technique. All patients also underwent subsequent vNOTES hysterectomy and bilateral salpingo-oophorectomy. The median age was 69.5 years, median total operative time was 126 min and the median estimated blood loss was 80 mL. In 97% of the cases bilateral sentinel nodes could be identified. A total of 60 patients had negative sentinel nodes, three had isolated tumor cells and one had macroscopically positive sentinel nodes. No complications with sequel occurred. CONCLUSIONS: This prospective multicenter case series demonstrates the feasibility of the vNOTES approach for identifying and removing sentinel lymph nodes in women with endometrial carcinoma successfully and safely. vNOTES allows sole transvaginal access with exposure of the entire retroperitoneal space, following the natural lymph trajectory caudally to cranially, and without the need for a Trendelenburg position.

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

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

vNOTES retroperitoneal transient uterine artery occlusion: a new approach to control bleeding during a high-risk evacuation of products of conception.

OBJECTIVE: To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery. DESIGN: Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval. SETTING: Teaching hospital. PATIENT(S): A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines. INTERVENTION(S): A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy. CONCLUSION(S): Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.

[vNOTES hysterectomy - a new minimally invasive method for gynecologic surgery]. / vNOTES ­ en ny minimalinvasiv metod för gynekologisk kirurgi.

vNOTES hysterectomy is a scarless minimally invasive method with a vaginal approach to the abdominal cavity combined with endoscopic overview. Studies have shown that patients who underwent vNOTES hysterectomy had less pain and shorter hospital stay than after laparoscopic hysterectomy.

Old meets new: vNOTES retroperitoneal promontory fixation in conjunction with the uterus preserving Manchester procedure✰,✰✰.

INTRODUCTION AND HYPOTHESIS: The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.

Relation between perinatal outcome and gestational duration in term primiparous pregnancies stratified by body mass index.

INTRODUCTION: There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies. MATERIAL AND METHODS: The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005-2017 (n = 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level. RESULTS: The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07-1.48. Among women with BMI ≥30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR = 1.95; 95% CI 1.07-3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5 minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27-1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI ≥30, this magnitude of risk was found already at 39+3 weeks. CONCLUSIONS: In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5 minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.

Obstetric anal sphincter injuries-Maternal, fetal and sociodemographic risk factors: A retrospective register-based study.

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potentially serious long-term consequences and large impact on quality of life. The aim was to determine risk and protective factors for OASIS. MATERIAL AND METHODS: We performed a retrospective register-based observational study. A cohort of 988 988 singleton term deliveries 2005-2016 in Sweden were included. Data from the Swedish Medical Birth Registry and Statistics Sweden were extracted to identify cases of OASIS and maternal and fetal characteristics. Modified Poisson Regression analyses were performed to assess risk factors. RESULTS: The rate of OASIS was 3.5% (n = 34 583). Primiparity (adjusted risk ratio [aRR] 3.13, 95% CI 3.05-3.21), vacuum extraction (aRR 2.79, 95% CI 2.73-2.86), forceps (aRR 4.27, 95% CI 3.86-4.72), and high birthweight (aRR 2.61, 95% CI 2.50-2.72) were associated with a significantly increased risk of OASIS. Increasing maternal age and decreasing maternal height also increased the risk of OASIS. Obesity increased the risk of OASIS (aRR 1.04, 95% CI 1.04-1.08), if fetal birthweight was not adjusted for. Smoking (aRR 0.74, 95% CI 0.70-0.79) and low maternal education (aRR 0.87, 95% CI 0.83-0.92) were associated with a decreased frequency of reported OASIS. Previous cesarean section increased the risk of OASIS (aRR 1.41, 95% CI 1.36-1.47). CONCLUSIONS: Primiparity, instrumental delivery, and high birthweight significantly increased the risk of OASIS. Obesity, low height, increasing age, and previous cesarean section also increased the risk whereas smoking and low maternal educational level were associated with a lower OASIS rate.

Planned cesarean section vs planned vaginal delivery among women without formal medical indication for planned cesarean section: A retrospective cohort study of maternal short-term complications.

INTRODUCTION: Rates of delivery by cesarean section have gradually risen in many parts of the world, and it is regarded as a safe surgical procedure with expanded indications. We assessed maternal complications within 6 weeks postpartum after planned cesarean section and after planned vaginal delivery among patients without medical indication for cesarean section. MATERIAL AND METHODS: This was a retrospective cohort study based on Swedish national registers and included 714 326 deliveries from 2008 to 2017. The study group consisted of cephalic, singleton, term pregnancies and excluded those with previous cesarean or pregnancy conditions that would qualify for cesarean section. We compared the risks of short-term complications between planned cesarean section and planned vaginal delivery. We obtained adjusted risk ratios (ARRs) using modified Poisson regression models adjusting for maternal age, parity, body mass index, smoking, country of birth, and county. RESULTS: The outcomes studied were infections and thromboembolism. In the planned cesarean section group (n = 22 855), 15% had a postpartum infection compared with 10% in the planned vaginal group (n = 691 471) (ARR 1.6; 95% confidence interval [CI] 1.5-1.6), and 0.08% vs 0.05% had a postpartum pulmonary embolism (ARR 1.7; 95% CI 1.0-2.6). The obtained risk estimates corresponded to "number needed to harm" estimates of 17 and 3448, respectively. When dividing the infections into subgroups, the risk of endometritis (ARR 1.2; 95% CI 1.1-1.3), wound infection (ARR 2.7; 95% CI 2.4-3.0), urinary tract infection (ARR 1.5; 95% CI 1.3-1.7), and mastitis (ARR 2.0; 1.9-2.2) was higher after planned cesarean section. CONCLUSIONS: Among patients without medical indication for planned cesarean section, the risks of short-term maternal complications were higher with planned cesarean section than with planned vaginal delivery.

Standardized 10-step approach for successfully performing a hysterectomy via vaginal natural orifice transluminal endoscopic surgery.

Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES.

Improved neonatal outcome after active management of prolonged pregnancies beyond 41+2 weeks in nulliparous, but not among multiparous women.

INTRODUCTION: Prolonged pregnancies are associated with adverse maternal and fetal outcome. In Sweden, no national guidelines exist for when to induce prolonged pregnancies. MATERIAL AND METHODS: Singleton cephalic prolonged pregnancies (defined as ≥ 41+3 gestational weeks) during 2001-2013 (n = 199 770) were identified using the Swedish Medical Birth Register. The maternity units were divided into three groups (tertiles) based on the proportion of pregnancies ≥ 42+3 gestational weeks among all pregnancies ≥ 41+3  weeks. The pregnancy outcome among women delivered at the units with the most expectant management of prolonged pregnancies (> 17.6% proceeding to 42+3  weeks), was compared with that among women delivered at units with the most active management (< 12.6% proceeding to 42+3  weeks). Odds ratios (OR) were calculated using simple and multiple logistic regression. Adjustments were made for year of delivery, hospital level, maternal age, body mass index, and smoking. RESULTS: Among primiparas, an increased risk of Apgar score < 7 at 5 minutes [odds ratio (OR) 1.27, 95% CI 1.16-1.41] and meconium aspiration (OR 1.49, 95% CI 1.14-1.95) was found after birth at most expectant units compared with most active units, but among multiparas, no such associations were detected. A decreased rate of cesarean section was found for both primiparas (OR 0.83, 95% CI 0.80-0.86) and multiparas (OR 0.82, 95% CI 0.77-0.86) at units with expectant vs. active management. No association between perinatal death and delivery-unit specific management of prolonged pregnancies was detected. CONCLUSIONS: Offspring to primiparas might gain from a more active management of prolonged pregnancies, whereas no such improvement of neonatal outcome among multiparous women was detected.

Risk of Abdominal Surgery in Pregnancy Among Women Who Have Undergone Bariatric Surgery.

OBJECTIVE: To compare the rates of abdominal surgery during pregnancy among women with previous bariatric surgery (women in the case group) and women with first-trimester body mass index (BMI) greater than 35 and no previous bariatric surgery (women in the control group). METHODS: We conducted a national cohort study, merging data from the Swedish Medical Birth Registry and the Swedish National Patient Registry, comparing women who had bariatric surgery from 1987 to 2011 with women in a control group with first-trimester BMI greater than 35 who had not had bariatric surgery. Primary outcome variables were diagnosis and surgical procedure codes grouped as five outcome categories: 1) intestinal obstruction, 2) gallbladder disease, 3) appendicitis, 4) hernia, and 5) diagnostic laparoscopy or laparotomy without the presence of a diagnosis or surgical code for outcomes in outcome categories 1-4. Odds ratios were computed using multivariate linear regression analysis for each separate pregnancy. For all pregnancies in a given woman, general estimating equations with robust variance estimation were used. Adjustment was made for smoking, year of delivery, maternal age, and previous abdominal surgery. RESULTS: During the first pregnancy after bariatric surgery, the rate of surgery for intestinal obstruction was 1.5% (39/2,543; 95% confidence interval [CI] 1.1-2.0%) in women in the case group compared with 0.02% (4/21,909; 95% CI 0.0-0.04%) among women in the control group (adjusted odds ratio [OR] 34.3, 95% CI 11.9-98.7). Similarly, the rate of diagnostic laparoscopy or laparotomy was 1.5% (37/2,542; 95% CI 1.0-1.9%) among women in the case group compared with 0.1% (18/21,909; 95% CI 0.0-0.1%) among women in the control group (adjusted OR 11.3, 95% CI 6.9-18.5). CONCLUSION: Bariatric surgery is associated with an increased risk of abdominal surgery during pregnancy.

Apgar scores at 5 minutes after birth in relation to school performance at 16 years of age.

OBJECTIVE: To estimate the association between an Apgar score of less than 7 at 5 minutes after birth and long-term cognitive function. METHODS: A linkage between the Swedish Medical Birth Registry and the Swedish School Grade Registry was performed. All singletons born from 1973 to 1986 after 36 6/7 weeks of gestation to Swedish-born women were included. Fetuses that were stillborn, newborns who had congenital malformations or were small for gestational age, and children who died or emigrated before 16 years of age were excluded from the analysis. RESULTS: The study included 877,618 individuals in the analysis. Newborns with Apgar scores less than 7 at 5 minutes after birth showed a significantly increased risk of never receiving graduation grades, presumably because they went to special schools because of cognitive impairment or other special educational needs (odds ratio 1.93, 95% confidence interval 1.75-2.14). One out of 44 newborns (numbers needed to harm) with an Apgar score of less than 7 at 5 minutes after birth will go to a special school because of the antenatal or perinatal factors that caused the low Apgar score. Nearly all school children who had Apgar scores of less than 7 at 5 minutes after birth showed an increased risk of graduating from compulsory school without graduation grades in that specific subject or receiving the lowest possible grades and were also less likely to receive the highest possible grade. CONCLUSION: An Apgar score of less than 7 at 5 minutes after birth is associated with subtle cognitive impairment, as measured by academic achievement at 16 years of age. LEVEL OF EVIDENCE: II.

Rhabdomyosarcoma.

Rhabdomyosarcoma, the most common soft tissue sarcoma of children, carried a 10-15% survival rate in the late 1960s. Since then, better understanding of biology and pathology of the tumor and the judicious use of chemotherapy and radiation has improved the prognosis drastically. In addition instead of extirpative surgery, organ salvage is now feasible in many of these children. In this article the authors review current information regarding pathology, diagnosis and treatment of rhabdomyosarcoma.

Continent catheterizable urinary conduit constructed from defunctionalized colon.

The authors describe a technique for construction of a continent catheterizable stoma from distal defunctionalized colon in a patient with imperforate anus, urethral atresia, and sacral agenesis.