The efficacy and safety of cervical polypectomy with vaginoscopy in pregnant women.

PURPOSES: This study aims to assess the effectiveness and safety of cervical polypectomy performed via vaginoscopy in pregnant women. METHODS: Pregnant patients diagnosed with cervical polyps were retrospectively included in Beijing Tiantan Hospital between April 2017 and April 2023. Group A underwent cervical polypectomy using a vaginoscopy technique without speculum, cervical forceps and anesthesia, while Group B received conservative management. The incidence of spontaneous abortion, preterm birth, preterm rupture of membranes (PROM), visual analog scale (VAS) scores, timing and method of delivery, and neonatal outcomes were analyzed. RESULTS: Of 90 pregnant patients included in the study, 48 patients receiving polypectomy under vaginoscopy were included into group A while 42 patients receiving conservative treatment were assigned into group B. At baseline, group A exhibited higher rates of vaginal bleeding pre-operation, as well as larger cervical polyp dimensions compared to group B. The median interval between vaginal bleeding and polypectomy was 3.5 weeks, with the median procedure typically performed at gestational week 19 in group A. There was no significant difference in the incidence of spontaneous abortion between the two groups (4.2% vs. 4.8%, p = 1.000). However, group A showed a significantly lower frequency of preterm birth (4.2% vs. 21.4%, p = 0.030) and premature rupture of membranes (PROM) (18.8% vs. 45.2%, p = 0.025) compared to group B. No disparities were observed in the timing, mode of delivery, and neonatal outcomes between the two groups. CONCLUSIONS: The utilization of vaginoscopy for cervical polypectomy has been shown to decrease the likelihood of preterm delivery and premature rupture of membranes in pregnant women with symptomatic cervical polyps. Therefore, performing cervical polypectomy via vaginoscopy without anesthesia provide a feasible and optimal ways in the management of this population.

Performance of Different Follow-Up Strategies and Genotype-Based Recurrence Risk After Treatment of Cervical High-Grade Squamous Intraepithelial Lesion.

OBJECTIVE: Our aim was to evaluate the performance of different follow-up strategies after treatment for cervical intraepithelial neoplasia (CIN) 2 or 3, including human papillomavirus (HPV) detection, cytology, or colposcopy, as well as their combinations. Additionally, we compared the influence of the persistence of HPV 16/18 versus that of other high-risk HPV genotypes (HR-HPV) in the recurrence risk. METHODS: Retrospective register-based study, including women who had an excision of the transformation zone for CIN2 or CIN3 at our institution, between January 2011 and December 2022. The outcome assessed was histopathological recurrence/persistence of CIN2 or worse. RESULTS: Of the 721 women included, 6.8% (49/721) had recurrence/persistence. The sensitivity, specificity, and positive and negative predictive values of the HPV test were 97.4%, 80%, 22.3%, and 99.8%, respectively, whereas for cotesting (HR-HPV and cytology), 86.8%, 90.1%, 34.4%, and 99.1%, respectively. The referral rates for colposcopy were 24.3% and 14.2%, respectively. The sensitivity of colposcopy was low (40.0%).Women who were initially positive for non-16/18 genotypes at baseline who became HPV16/18 positive during follow-up, had a statistically significant increased risk of CIN2 or worse, compared with those who tested positive only for other HR-HPV genotypes during both stages (hazard ratio = 4.98; 95% CI = 1.66-14.91). CONCLUSIONS: Human papillomavirus testing is the best strategy for follow-up after treatment of cervical HSIL. The addition of cytology triage decreases by more than 40% the referrals for colposcopy, without significantly missing cases of recurrence/persistence. Human papillomavirus 16/18 in the follow-up, regardless of being previously positive, is associated with higher risk of recurrence/persistence of HSIL.

Efficacy of Listening to Music on Pain Reduction during Colposcopy-Directed Cervical Biopsy: A Randomized, Controlled Trial.

Background and Objective: To investigate the efficacy of listening to music on pain reduction during colposcopy-directed cervical biopsy (CDB). Materials and Methods: From June 2020 to November 2021, 240 women undergoing CDB were enrolled. The participants were randomized into three groups: Group 1, colposcopic examination while wearing headphones and listening to music; Group 2, colposcopy while wearing headphones but not listening to music; Group 3 (control group), colposcopy while neither listening to music nor wearing headphones. All participating women completed a 10 cm visual analog scale for subjective pain at three time points: baseline, immediately after cervical biopsy, and 15 min after the procedure. The primary endpoint was the biopsy pain score. Result: Of the 240 women, a sample size of 80 was randomly assigned per group. The clinical-pathological and procedure-related characteristics of the participants in all groups were similar. The mean baseline pain score between each group was not significantly different (2.83 in the music group, 2.54 in group 2, and 2.94 in the control group, p = 0.47). There were no significant differences between each group in terms of mean biopsy pain score (4.21 in the music group, 4.24 in group 2, and 4.30 in the control group, p = 0.98). The differences in changes between the baseline pain score and the biopsy pain score were not statistically significant (1.39 in the music group, 1.70 in group 2, and 1.36 in the control group, p = 0.69). In the multiple comparison analysis, the differences in changes between the biopsy pain score and the baseline pain score between each group were also not statistically significant. There were no complications with the intervention observed. Conclusion: This study demonstrated that there was no beneficial effect of listening to music on pain reduction during colposcopy-directed cervical biopsies.

[Effectiveness of Different Testing Strategies Applied for Cervical Cancer Screening in Shuangliu District, Chengdu City].

Objective: To evaluate the clinical value of different combination strategies of high-risk HPV (hr-HPV) testing and Thinprep cytology test (TCT), a cervical cytology test, for cervical cancer screening, especially for high or higher-grade squamous intraepithelial lesion (HSIL+) in Shuangliu District, Chengdu City. Methods: The study is a population-based randomized clinical trial. Women aged 35 to 65 years meeting the inclusion criteria were enrolled for the study. At the baseline screening conducted in the first year, the participants were randomly assigned to either cytology test or hr-HPV testing at a ratio of 1∶2. If the paticipants had positive results for the baseline hr-HPV test, they would then undergo either cytology test or colposcopy by random assignment. After 24 months, all participants were called back, and combined screening of cytology test and hr-HPV test were performed. Women who had negative results at baseline screening and who entered and completed the third-year follow-up were selected as the subjects of the study. Based on the aforementioned testing findings, the related data were extracted and four different screening protocols were simulated: 1) combined TCT and hr-HPV screening, with referral for colposcopy when there was positive results for either one of the two; 2) combined TCT and hr-HPV screening, with referral for colposcopy when both tests had positive results at the same time; 3) TCT was done for preliminary screening and those who were found to be positive would then undergo hr-HPV test for triage purpose, with subsequent referral made for colposcopy if the hr-HPV results were positive; 4) hr-HPV was done for preliminary screening and those who were found to be positive would then undergo TCT, with subsequent referral made for colposcopy if TCT results were positive. With the detection of HSIL+ on histological examination as the endpoint event, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve ( AUC) of different combination screening models were calculated. Results: A total of 3102 women were screened, and 2967 women were included in the statistical analysis in this study. Among the 2967 women, 979 were randomized to cytology and 1988 to hr-HPV genotyping. For prescreening, the positive rate of the cytology group was 5.6% (55/979), with of HSIL+ positive rate being 0.2% (2/979), while the positive rate of the hr-HPV group was 7.5% (149/1988), with HSIL+ positive rate being 0.9% (18/1988). After 24 months, 2456 women were called back and were given cervical cytology test and hr-HPV test at the same time. Among them, the positive rate of the cytology group was 3.2% (78/2456), while the positive rate of hr-HPV group was 8.7% (215/2456). The overall positive rate of HSIL+ was 0.69%(17/2456). Women with a negative baseline hr-HPV had a lower incidence of HSIL+ lesions in the long term. The strategy of cervical cytology screening combined with hr-HPV test for triage purpose is the best method, with a sensitivity of 88.9%, a specificity of 58.3%, a PPV of 44.4%, a NPV of 93.3%, and an AUC of 0.736, P=0.039 (95% CI: 0.555-0.917). Conclusion: This randomized clinical trial from Shuangliu District, Chengdu City shows that the sensitivity of hr-HPV testing is better than that of cytology test, and the prevalence of HSIL+ in women with negative baseline hr-HPV results is lower than that of women with negative baseline cytology results. The screening program of TCT for prescreening plus subsequent hr-HPV test for triage purpose shows better value for the detection of HSIL+.

Complications and clinical outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse.

Evidence on laparoscopic sacrocolpopexy (LSC) is lacking. Herein, we describe the complications and outcomes of LSC. This single-centre, retrospective cohort study included women with pelvic organ prolapse (POP) who underwent LSC between 2015 and 2017. Preoperative, intraoperative, postoperative, and demographic data were collected. We evaluated patients using the Pelvic Organ Prolapse Quantification system and questionnaires. The primary outcomes were operative characteristics, perioperative complications, early postoperative complications, and anatomical results at 12 months. Forty-six patients (median age: 71 years) underwent LSC. The median follow-up period was 12.0 ± 5.0 (range: 11-26) months. The perioperative complications were bladder perforation and vaginal injury (2.2%). Two (4.3%) patients required reoperation for port-site hernia. One (2.2%) patient developed a retroperitoneal abscess, and one (2.2%) had worsened stress urinary incontinence after LSC. Three (6.5%) patients presented with recurrence of prolapse. LSC is safe and effective for POP.IMPACT STATEMENTWhat is already known on this subject? Laparoscopic sacrocolpopexy (LSC) has become a widely used intervention strategy during the last decade; nevertheless, few studies have reported its outcomes and complications.What do the results of this study add? We demonstrate that LSC for pelvic organ prolapse (POP) has favourable anatomical and voiding functional results, and few perioperative complications. However, it is important to preoperatively inform patients regarding the incidence of mesh-related postoperative complications, although they are not life-threatening, and secure their informed consent.What are the implications of these findings for clinical practice and/or further research? We believe that the LSC procedure, because of its short-term and functional outcomes in the lower urinary tract discussed here, will be more commonly available in clinical practice as a feasible and safe surgical option for POP. However, prospective, large-sample studies should be performed to verify the efficacy of LSC, as further evaluation of the procedure is required.

The challenges of colposcopy for cervical cancer screening in LMICs and solutions by artificial intelligence.

BACKGROUND: The World Health Organization (WHO) called for global action towards the elimination of cervical cancer. One of the main strategies is to screen 70% of women at the age between 35 and 45 years and 90% of women managed appropriately by 2030. So far, approximately 85% of cervical cancers occur in low- and middle-income countries (LMICs). The colposcopy-guided biopsy is crucial for detecting cervical intraepithelial neoplasia (CIN) and becomes the main bottleneck limiting screening performance. Unprecedented advances in artificial intelligence (AI) enable the synergy of deep learning and digital colposcopy, which offers opportunities for automatic image-based diagnosis. To this end, we discuss the main challenges of traditional colposcopy and the solutions applying AI-guided digital colposcopy as an auxiliary diagnostic tool in low- and middle- income countries (LMICs). MAIN BODY: Existing challenges for the application of colposcopy in LMICs include strong dependence on the subjective experience of operators, substantial inter- and intra-operator variabilities, shortage of experienced colposcopists, consummate colposcopy training courses, and uniform diagnostic standard and strict quality control that are hard to be followed by colposcopists with limited diagnostic ability, resulting in discrepant reporting and documentation of colposcopy impressions. Organized colposcopy training courses should be viewed as an effective way to enhance the diagnostic ability of colposcopists, but implementing these courses in practice may not always be feasible to improve the overall diagnostic performance in a short period of time. Fortunately, AI has the potential to address colposcopic bottleneck, which could assist colposcopists in colposcopy imaging judgment, detection of underlying CINs, and guidance of biopsy sites. The automated workflow of colposcopy examination could create a novel cervical cancer screening model, reduce potentially false negatives and false positives, and improve the accuracy of colposcopy diagnosis and cervical biopsy. CONCLUSION: We believe that a practical and accurate AI-guided digital colposcopy has the potential to strengthen the diagnostic ability in guiding cervical biopsy, thereby improves cervical cancer screening performance in LMICs and accelerates the process of global cervical cancer elimination eventually.

Complications after pelvic floor repair surgery (with and without mesh): short-term incidence after 1873 inclusions in the French VIGI-MESH registry.

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.

Short-term Outcomes of Non-robotic Single-incision Laparoscopic Sacrocolpopexy: A Surgical Technique.

STUDY OBJECTIVE: Our main purpose was to describe the surgical technique and short-term outcomes of single-incision laparoscopic sacrocolpopexy (S-LSC) for the treatment of pelvic organ prolapse (POP). DESIGN: This study consisted of a retrospective analysis of 49 consecutive cases. SETTING: This study was set at the Third Affiliated Hospital of Guangzhou Medical University from October 2016 to November 2017. PATIENTS: The population for this study consisted of women with stage II to IV POP who met eligibility criteria for laparoscopic surgery. INTERVENTIONS: S-LSC included the use of V-loc barbed suture and retroperitoneal tunneling, in addition to standard single-incision laparoscopic surgery techniques. All 49 cases were successfully completed. All cases included concomitant procedures; 42 (85.7%) had removal of the uterus and adnexa. The main measured outcomes include patient characteristics, perioperative outcomes, and change in pelvic floor support (Pelvic Organ Prolapse Quantification System), and quality of life (Pelvic Floor Impact Questionnaire). MEASUREMENTS AND MAIN RESULTS: All patients were parous, and 42.9% had a history of previous abdominal surgery. The mean operative duration from skin to skin was 201.20 ± 46.53 minutes. The mean estimated blood loss was 27.0 ± 16.6 mL. The mean pre- and post-operative Pelvic Organ Prolapse Quantification System scores were 2.2 ± 1.1 cm versus -2.6 ± 0.5 cm for the Aa point and 3.2 ± 2.8 cm versus -4.6 ± 0.8 cm for the C point (p <.05 for both). The mean pre- and post-operative Pelvic Floor Impact Questionnaire scores were 106.4 ± 18.9 versus 8.9 ± 4.26 (p <.05), suggesting that S-LSC significantly improved physical prolapse and quality of life. Four patients suffered from postoperative complications (3 mesh exposure and 1 lumbosacral pain). Six patients complained of new onset of stress urinary incontinence. CONCLUSIONS: Single-incision laparoscopic sacrocolpopexy is a feasible method to manage POP. However, the long-term effects and complications need to be further investigated.

Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database.

STUDY OBJECTIVE: The objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH). DESIGN: This was a retrospective cohort study. A secondary analysis of the 2006-2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned. SETTING: Hospitals participating in the NSQIP program. PATIENTS: Women who underwent hysterectomy with MISCP. INTERVENTIONS: Not applicable. MEASUREMENT AND MAIN RESULTS: A total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3-3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome. CONCLUSION: Regardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.

Risk of Cervical Dysplasia After Colposcopy Care and Risk-Informed Return to Population-Based Screening: A Systematic Review.

This systematic review examined the risk of cervical dysplasia among women who have undergone a colposcopy episode of care to inform their return to population-based cervical screening. PubMed, Embase, and grey literature were searched between January 2000 and 2018. One reviewer screened citations against pre-defined eligibility criteria. A second reviewer verified 10% and 100% of exclusions at title and abstract and at full-text screening, respectively. One reviewer extracted data and assessed methodological quality of included articles; a second reviewer verified these in full. The primary outcome was incidence of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) subsequent to initial colposcopy evaluation. Secondary outcomes included incidence of CIN2+ after negative follow-up test results and performance of follow-up strategies. Results were synthesized narratively. A total of 48 studies were included. The 1- to 5-year CIN2+ risks after colposcopy evaluation ranged from 2.4% to 16.5% among women treated for CIN2+ and from 0.7% to 16.8% among women untreated for CIN grade 1 or less (≤CIN1). Follow-up strategies included single or repeat cytology, human papillomavirus (HPV) testing, or combined HPV/cytology co-testing at various intervals. After negative follow-up test results, risk varied by follow-up strategy for both groups and by referral cytology severity for untreated women. Performance of follow-up strategies varied among treated women. Among untreated women, co-testing demonstrated greater sensitivity than cytology alone. In conclusion, women treated during colposcopy for CIN2+ and women with ≤CIN1 who were referred to colposcopy for low-grade cytology and who did not receive treatment may be able to return to population-based screening after negative co-testing results. Current evidence does not suggest that women untreated for ≤CIN1 who are referred for high-grade cytology be returned to screening at an average risk interval. The optimal strategy for colposcopy discharge needs ongoing evaluation as implementation of HPV testing evolves.

Cervical Screening and Colposcopy Management of Women Age 24 and Under.

OBJECTIVES: In 2012, Ontario's cervical cancer screening program changed the age of initial screening from 18 years of age to 21 and identified women aged 21-24 years as a special population whose cervical squamous intraepithelial lesions should be managed conservatively. In order to provide insight into these changes, we sought to examine patient, provider, and clinical characteristics of cervical cancer screening and colposcopy care in women aged 12-24 years. METHODS: We conducted a retrospective population-based cohort study of all women in Ontario, aged 12-24 years, who underwent a Pap test between 2012 and 2014. Variables measured included, patient age, cytologic result of the index Pap test; colposcopy and definitive treatment within 1.5 years of the index Pap test; and carcinoma in situ (CIS) and invasive cervical cancer (ICC) 1.5 years after the index Pap test. Descriptive statistics were calculated for variables, and incidence rates per 100 000 women screened were calculated for CIS and ICC. RESULTS: A total of 270 391 index Pap tests were performed. The majority of patients were between 18 and 24 years of age (12-17 y: 5.5%; 18-20 y: 24.3%; 21-24 y: 70.1%). Overall, 87.0% of Pap tests were normal, 6.9% of women underwent subsequent colposcopy, and 1.1% received any treatment. Of women with a high-grade result, 86.6% (n = 1279) underwent colposcopy and 42.8% (n=632) received any treatment. Of women with a low-grade result, 42.3% (n = 13 856) underwent colposcopy, and 6.0% (n = 1955) had any treatment. Age-standardized rates of CIS and ICC in were 161.5 and 1.0 per 100 000 women, respectively. CONCLUSIONS: Despite the change in the screening guidelines, women under the age of 21 continue to be screened. This study highlights the low risk of ICC in women under age 25 and lays groundwork for re-examining screening guidelines for women in this age group. Furthermore, colposcopy referrals for women with a low-grade result on an index Pap test, and treatment of women under 24 years of age continue to be high. Future work must address the over-utilization of population-based screening, as well as factors related to adherence to screening guidelines.

Long-term subjective, clinical and sonographic outcomes after native-tissue and mesh-augmented posterior colporrhaphy.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to describe long-term outcomes after posterior colporrhaphy with and without mesh augmentation. METHODS: This was a retrospective study including 93 patients after posterior colporrhaphy (native tissue in 39 and synthetic mesh augmented in 54). The indication was symptoms of prolapse with clinical posterior vaginal wall prolapse. Mesh augmentation and concomitant prolapse operations were performed at the surgeon's discretion. Patients underwent interview, clinical examination and 4D pelvic floor ultrasound. Imaging analysis was done with the reviewer blinded against all other data. Generalized linear modeling was used to compare groups with logistic regression for binary and linear regression for continuous outcomes. RESULTS: Patients were seen on average 5.3 years after surgery and described persistent symptoms of prolapse in 32% and of obstructed defecation in 33%. Clinical recurrence (Bp ≥ -1) was seen in 20%, while sonographic recurrence (rectal ampulla descent to ≥ 15 mm below the symphysis pubis) was noted in 12%. A true rectocele was diagnosed in 33% of patients. No major differences in outcomes were found between those who underwent native tissue and those who had a mesh-augmented repair. CONCLUSIONS: Mesh augmentation was not superior to native tissue posterior colporrhaphy, and both were only moderately effective in eliminating a true rectocele and symptoms of obstructed defecation 5 years after reconstructive surgery.

Comparison of topical lidocaine spray with forced coughing in pain relief during colposcopic biopsy procedure: a randomised trial.

Our objective was to compare the effectiveness of local lidocaine spray (LS) compared to forced coughing (FC) for relieving the pain during colposcopically guided cervical biopsies (CGBs). The study was a randomised study, which included patients with abnormal cervical cytologic results requiring a colposcopic biopsy procedure. The patients were randomly assigned to either the 10% LS or the FC groups before the biopsy procedure. As a primary outcome, the pain was assessed by using a 10 cm visual analogue scale at the different steps during the procedure. Forty-four and 42 patients had CGBs using LS and FC, respectively. The age, parity, body mass index, history of previous curettage and vaginal delivery, smoking status and the number of biopsies were similar in both groups. The mean ± SD pain scores after the cervical biopsy were 3.25 ± 1.4 and 4.4 ± 1.3 in the LS and FC groups, respectively (p< .05). The operative time was longer in the LS than in the FC group (7.6 ± 1.4 vs. 5.2 ± 0.8, p: .004). No complication or adverse effect was observed in both groups. The present study showed that LS use can be recommended for pain relief during colposcopically directed cervical biopsy procedure with a superiority to the FC in the terms of pain and absence of any adverse reactions. Impact Statement What is already known on this subject? A colposcopic-guided cervical biopsy is a painful procedure and different techniques have been proposed to relieve this pain with conflicting results. Studies have demonstrated that a forced coughing is a good and easy method for relieving pain with some disadvantages. Local lidocaine spray (LS) is another option for pain relief during the biopsy procedure. However, no randomised study has compared these two methods yet. What the results of this study add? The results from this randomised study suggest that LS has superiority in terms of pain relief during the colposcopic biopsy procedure and has no adverse reactions. What the implications are of these findings for clinical practice and/or further research? The evidence from different studies showed some conflicting results regarding the pain relief methods during the colposcopic biopsy procedure. The local LS can be used in this procedure in routine clinical practice. However, further studies with larger samples and comparison of different methods are needed.

TWENTY-YEAR EXPERIENCE WITH LARGE LOOP EXCISION OF THE TRANSFORMATION ZONE AT SESTRE MILOSRDNICE UNIVERSITY HOSPITAL CENTRE.

The 20-year experience with large loop excision of the transformation zone (LLETZ) at Gynecologic Oncology Unit, Department of Gynecology and Obstetrics, Sestre milosrdnice University Hospital Centre from Zagreb is presented. This retrospective observational study included 1407 women with cervical dysplasia treated by LLETZ technique during the 1995-2016 period. LLETZ was most commonly performed in the 25-35 age group (51%), followed by the 36-45 age group (22%), and least frequently in the >65 age group (2%). Histopathologic results lower than high-grade squamous intraepithelial lesion were found in 23% and high grade squamous intraepithelial lesion or worse findings in 77% of patients. Positive margin as a sign of possible residual dysplasia was found in 25% of cones, 80% of which included endocervical positive margin. Cervical canal biopsy result was positive in 18% of cases. Accurate colposcopy and its findings can help avoid overtreatment, the rate of which was higher than expected in our retrospective study. Long-term follow up is an imperative for proper assessment of the procedure success. This method is the best choice for complete disease removal without unnecessary overtreatment, but it requires continuous education and training of the whole team.

A National Contemporary Analysis of Perioperative Outcomes of Open versus Minimally Invasive Sacrocolpopexy.

PURPOSE: We evaluated the perioperative morbidity of open abdominal sacrocolpopexy and minimally invasive sacrocolpopexy using data on a contemporary nationwide cohort. MATERIALS AND METHODS: We used the ACS (American College of Surgeons) NSQIP® (National Surgical Quality Improvement Program) database to identify women who underwent abdominal or minimally invasive sacrocolpopexy from 2010 to 2016. Associations of surgical approach with 30-day complications, blood transfusion, prolonged hospitalization and reoperation were evaluated by logistic regression. Hospital readmission within 30 days was calculated by the person-years method and Cox proportional hazard models. RESULTS: A total of 4,362 women underwent sacrocolpopexy, including abdominal sacrocolpopexy in 1,179 (27%) and minimally invasive sacrocolpopexy in 3,183 (73%). The proportion of minimally invasive sacrocolpopexy increased during the study period from 70% in 2010 to 82% in 2016. Baseline characteristics were similar between the treatment groups aside from a higher rate of chronic obstructive pulmonary disease (p = 0.03) and higher preoperative albumin (p <0.0001) among abdominal sacrocolpopexy cases. Compared to abdominal sacrocolpopexy, minimally invasive sacrocolpopexy was associated with lower rates of 30-day complications (p = 0.001), deep vein thrombosis/pulmonary embolism (p = 0.02), surgical site infections (p <0.0001), shorter hospitalization (p <0.0001) and fewer blood transfusions (p = 0.01). Minimally invasive sacrocolpopexy was also associated with a lower 30 person-days readmission rate (2% vs 2.7%, p ≤0.0001) and 30-day reoperation rate (1.1% vs 1.4%, p <0.0001). On multivariable analysis minimally invasive sacrocolpopexy was independently associated with a reduced risk of 30-day complications (OR 0.46, 95% CI 0.28, 0.76, p = 0.002), blood transfusion (OR 0.33, 95% CI 0.15, 0.74, p = 0.007), prolonged hospitalization (OR 0.16, 95% CI 0.12, 0.23, p <0.001) and readmission (HR 0.62, 95% CI 0.41, 0.96, p = 0.03). CONCLUSIONS: Minimally invasive sacrocolpopexy was associated with reduced rates of 30-day complications, blood transfusion, prolonged hospitalization and hospital readmission compared to abdominal sacrocolpopexy.

Laparoscopic management of severe ureteral obstruction after vaginal hysterectomy and colposuspension.

INTRODUCTION AND HYPOTHESIS: After vaginal hysterectomy, uterosacral ligaments are commonly used to suspend the vaginal vault in order to prevent and to treat recurrence of central prolapse. Shull et al. proposed a technique to fix endopelvic fascia and vagina to the higher portion of the uterosacral ligaments using a vaginal approach [1]. This technique is associated with a risk of ureteral obstruction (0-11%) [2, 3]. Although intraoperative cystoscopy is recommended to check ureteral patency at the end of colposuspension, this secondary prevention technique could be false negative due to partial stenosis [4]. METHODS: A 60-year-old woman with stage 3 uterine and anterior compartment descensus assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system underwent vaginal hysterectomy, bilateral adnexectomy, and vaginal vault suspension to the uterosacral ligaments using the Shull technique. Intraoperative cystoscopy with indigo carmine was negative. On postoperative day 0, the patient complained left flank pain. Transabdominal ultrasound showed a left hydroureteronephrosis without ureteral stones, which was confirmed by uro-computed tomography scan. The attempts of ureteral stent positioning and opening the vaginal vault failed to resolve the ureteral obstruction, which was corrected, and a new vault suspension performed using the laparoscopic approach. Prophylactic ureteral stent positioning was performed. Informed consent was obtained from the patient for publication of this case report. RESULTS: The patient was discharged on postoperative day 5 with normal renal function. The ureteral stent was removed after 1 month, and renal ultrasound at 3 and 6 months' follow-up showed normal renal pelvis caliber. No recurrence of genital prolapse was observed at gynecological examination. CONCLUSIONS: Laparoscopy can be a wise alternative option to manage ureteral obstruction secondary to vaginal colposuspension for genital organ prolapse.

Effects of Pneumoperitoneum and the Steep Trendelenburg Position on Heart Rate Variability and Cerebral Oxygenation during Robotic Sacrocolpopexy.

STUDY OBJECTIVE: The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy. DESIGN: Prospective study (Canadian Task Force classification III). SETTING: Rambam Health Care Campus. PATIENTS: Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse. INTERVENTIONS: Robotic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: A 5-minute computerized electrocardiogram, cerebral O2 saturation (cSO2), systemic O2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO2 at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms2/Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms2/Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation. CONCLUSION: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.

Vaginal Sacral Colpopexy: A Natural Orifice Approach to a Gold Standard Procedure.

STUDY OBJECTIVE: A transvaginal approach to sacral colpopexy has a natural appeal to those interested in minimally invasive pelvic reconstructive surgery. Development of an effective technique has been frustrated because of the technical difficulty of confining the dissection and placement of mesh to the retroperitoneal space. The objective of this prospective study is to describe the technique and report the outcomes of a transvaginal, retroperitoneal sacral colpopexy. DESIGN: Prospective cohort study (Canadian Task Force Design classification II-2). SETTING: Urogynecology of Southern Alabama private practice. PATIENTS: Women with stage 2 or greater apical prolapse. INTERVENTIONS: Surgical repair of apical prolapse using vaginal sacral colpopexy. MEASUREMENTS AND RESULTS: Over a 1-year period, 15 posthysterectomy patients with stage 2 or greater vaginal prolapse were recruited and consented to vaginal sacral colpopexy. Primary outcome was success of the repair, with success defined as a combination of objective and subjective parameters using pelvic organ prolapse quantification measures, and quality of life questionnaires. Secondary outcomes were complications and operating time. One case converted to a native tissue repair. The vaginal sacral colpopexy was completed in the remaining 14. Eleven patients have been followed for 1 year or longer. Two patients did not return after their 6-week examination because of chronic illness. They were contacted by telephone over 2 years after the surgery and expressed total satisfaction with the operation and the outcome. One patient was seen at 3 months and was noted to have an excellent anatomic result; however, a pelvic organ prolapse quantification evaluation was not done. She has been totally lost to further follow-up. There was 1 mechanical failure in which the titanium tacks securing the apex to the anterior longitudinal ligament dislodged and a second case with a stage 2 posterior compartment defect. One incidental cystotomy, and 1 incidental proctotomy occurred. These were both small, remote from the site of the vaginal mesh, and did not prevent completion of the procedure. There were no mesh-related complications. Mean operating time was 123 minutes. CONCLUSION: In this small pilot study, a transvaginal retroperitoneal sacral colpopexy is described and is demonstrated to be feasible and safe. Based on the experience gained, changes in technique have been implemented to prevent future mechanical tack failures. Assuming that these changes will be successful in preventing apical recurrence due to dislodgement of mesh from the anterior longitudinal ligament, a larger study is planned to determine efficacy. Inherent advantages of the transvaginal approach are discussed, including a favorable morbidity profile, full access to all compartments, short operating times, and decreased costs.

Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey.

OBJECTIVE: To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress. DESIGN: Longitudinal survey. SETTING: Two hospital-based colposcopy clinics. POPULATION: Women with abnormal cytology who underwent colposcopy (±related procedures). METHODS: Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables. MAIN OUTCOME MEASURES: Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress. RESULTS: Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up. CONCLUSIONS: The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress. TWEETABLE ABSTRACT: Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Conservative management of pelvic abscess following sacrocolpopexy: a report of three cases and review of the literature.

INTRODUCTION AND HYPOTHESIS: After sacrocolpopexy, intra-abdominal pelvic abscesses are often managed with intravenous antibiotics, excision of the mesh involved, and debridement of compromised tissue. METHODS AND RESULTS: Three cases of successful management of pelvic abscesses after sacrocolpopexy using long-term antibiotics and percutaneous drainage of intra-abdominal abscesses without removing the mesh are presented. CONCLUSIONS: In selected patients who have undergone sacrocolpopexy, with careful counseling, conservative management of pelvic abscesses with percutaneous drainage and long-term antibiotic treatment without the surgical excision of the mesh may play a role.