vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE: To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30. DESIGN: A retrospective cohort study. SETTING: A French teaching hospital. PATIENTS: All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma). INTERVENTIONS: Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m2). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management. MEASUREMENTS AND MAIN RESULTS: A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150). CONCLUSION: The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Comparing vNOTES Hysterectomy with Laparoscopic Hysterectomy for Large Uteri.

STUDY OBJECTIVE: Our study aimed to compare conventional laparoscopic hysterectomies (LHs) with vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies performed for patients with large uteri (weight >280 g) at our institution, which underwent a change in practice from conventional LH to vNOTES for large uteri. DESIGN: Retrospective cohort. SETTING: French tertiary university hospital. PATIENTS: Two cohorts: the last 54 patients who underwent vNOTES hysterectomy and the last 52 patients who underwent conventional LH for large uteri. INTERVENTION: Baseline characteristics and surgical outcomes were assessed, including uterine weight, mode of delivery for previous pregnancies, history of abdominal surgery, indication for hysterectomy, associated procedures, operative time (OT), complications, volume of intraoperative bleeding, and length of postoperative hospital stay. MEASUREMENTS AND MAIN RESULTS: Both groups were comparable, with a mean uterine weight of 586.4 ± 289.2 g in the laparoscopy group compared with 686.7 ± 374.6 g in the vNOTES group. There was a significant decrease in the OT in the vNOTES group with a median of 99 minutes (66.5-138.5 minutes) compared with 171 minutes (131-208 minutes) in the laparoscopy group, p <.001. The length of hospital stay was also decreased in the vNOTES group with a median of 0.5 nights compared with 2 nights in the laparoscopy group, p <.001. More patients were managed in an ambulatory setting in the vNOTES group (50% vs 3.7%, p <.001). Our study did not find any significant difference in terms of bleeding or the number of conversions to another surgical approach. The frequency of intraoperative and postoperative complications was very low. CONCLUSION: Compared with the laparoscopic approach, vNOTES hysterectomy for large uteri (>280 g) is associated with decreased OT, a shorter hospital stay, and increased performance in the ambulatory setting.

How we do an anterior sacrospinous ligament fixation for vaginal vault prolapse.

Since 2019, all vaginal mesh implants were removed from the market. Since, surgeons have only the autologous technique left to treat prolapse by vaginal route. The anterior sacrospinofixation is an alternative technique to treat vaginally apical prolapses. We have divided the anterior sacrospinous ligament fixation technique into 10 surgical steps: exposure, infiltration, vaginal incision, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture (two passage in the SSL on each side, using a suture-capturing device), vaginal fixation, vaginal closure, sacrospinous ligament fixation and final closure. We have performed more than 50 ASSF. This technique is not very well known, and the surgeons are more used to approach the SSL by posterior way. We have included a video of the procedure and an anatomical drawing exhibiting the dissection of the SSL without eyes control. We also added tips and tricks to easily apprehend this new technique. The anterior approach seems to has several advantages compared to the traditional posterior technique. We want to share such a video on showing how to approach the paravesical fossa anteriorly without eyes control.

How we perform a posterior sacrospinous ligament fixation by the vaginal route.

Posterior sacrospinous fixation (SSF) was first described by Amreich in 1950 and then modified by Richter in 1968. The main difficulty of this technique is the pararectal approach with dissection under visual guidance. Our aim was to teach young surgeons to use this alternative technique for apical suspension and to facilitate the pararectal approach. We divide the sacrospinous ligament fixation technique into ten surgical steps: exposure, infiltration, vaginal incision, recto-vaginal dissection, pararectal dissection, SSL suture, vaginal fixation (with vaginal strips), vaginal closure, SSF and final closure. We have performed > 500 SSFs following the sacrospinous ligament fixation technique. Inexperienced surgeons are generally not comfortable with the dissection of the SSL. A video of the procedure with pararectal dissection, SSL identification and suturing clearly shown can help to perform this technique. The use of vaginal strips has been designed to help strengthen the vaginal part of the SSF. It is important to share such a video showing how to approach the pararectal fossa with a dissection under visual guidance. The aim is to help young surgeons better understand the surgical technique and dissection.

Fertility, Pregnancy, and Clinical Outcomes after Uterine Arteriovenous Malformation Management.

STUDY OBJECTIVE: To evaluate fertility, pregnancy, and clinical outcomes after uterine arteriovenous malformation (UAVM) management. DESIGN: Single-center retrospective study (Canadian Task Force classification III). SETTING: One referral center. PATIENTS: Twenty-two patients with a UAVM diagnosed by magnetic resonance angiography or computed tomography angiography and managed by expectant management (EM) or uterine arterial embolization (UAE) during the study period were included. INTERVENTIONS: Nine of 22 patients underwent first-intention EM and 13 first-line UAE. Three of 9 EM patients (33.3%) required emergency second-intention UAE for nonresolution of the UAVM and severe genital bleeding. MEASUREMENTS AND MAIN RESULTS: To analyze fertility according to management approach, we defined 2 groups: EM only group (n = 6) and UAE group (n = 16; women who underwent first- or second-intention UAE). Overall, the median age was 29 years (range, 17-43). The mean follow-up after UAVM management was 39 months (range, 1-116). The success rate of the UAE procedure was 87.5% (14/16). Eight of 12 women (66.7%) who wished to conceive became pregnant: 2 of 5 (33.3%) in the EM group and 6 of 7 (85.7%) in the UAE group (p = 1). Overall, 11 patients (50%) conceived: 3 in the EM group (50%) and 8 in the UAE group (50%) (p = .9). The live birth rate was 36.4% (8/22) for the whole population. There were no miscarriages or ectopic pregnancies. The 8 women (72.7%) wishing to conceive who became pregnant all delivered: 1 by cesarean section and 7 by vaginal delivery. Median duration of pregnancy was 39 weeks and 5 days. The remaining 3 women (i.e., women who conceived but did not wish to become pregnant) had therapeutic abortions. One complication was experienced in the EM group (small for gestational age newborn) and none in the UAE group (p = .3). Limitations include retrospective design and small sample size. CONCLUSION: UAE for UAVM is an effective and safe technique. It does not impair fertility, and obstetric prognosis is good.

The transvaginal mesh: an overview of indications and contraindications for its use.

INTRODUCTION: In recent decades, concerns about safety of synthetic non-absorbable materials transvaginally implanted emerged. We aim to define the actual role of synthetic non-absorbable transvaginal mesh (TVM) for pelvic organ prolapse (POP) and mid-urethral sling (MUS) for stress urinary incontinence (SUI), in relation with the worldwide legislative evolution. AREAS COVERED: While in the United Kingdom MUS is not considered the first-line surgical option, other countries adopt MUS as the main procedure. United States, United Kingdom, Australia, New Zealand, France banned or paused TVM use for POP repair. At the same time, Germany, Asian, and South American countries adopt TVM after adequate counseling for selected populations such as women affected by or at high risk of POP relapse and contraindication for other surgical routes. EXPERT OPINION: The worldwide evolution of recommendations determined deep modification of clinical practice, with native tissue repair returning to forefront when the vaginal route is indicated. A more careful evaluation of the safety and efficacy profile of meshes' materials and the assessment of the minimal surgeon's expertise in performing TVM procedures became crucial. A multidisciplinary approach and a high specialization of the hospitals both in performing mesh procedures and in managing complications are mandatory.

Comparison of Early Postoperative Outcomes for Vaginal Anterior Sacrospinous Ligament Fixation with or without Transvaginal Mesh Insertion.

Pelvic organ prolapse affects one in three women, and cystocele accounts for 80% of the indications for surgery. Following the withdrawal of transvaginal mesh from the market, the objective of the present before-and-after study was to compare of the previous reference technique (UpholdTM (Boston Scientific, Marlborough, MA, USA) mesh insertion) with anterior sacrospinous ligament fixation with suturing in terms of the outcomes 2 months after surgery. We performed a retrospective, observational, before-and-after study at Lille University Medical Center (Lille, France) by including consecutive patients operated on between 2011 and 2018 for UpholdTM mesh insertion and between 2018 to 2020 for anterior sacrospinous ligament fixation. The primary outcome was the early recurrence of prolapse, and the secondary outcomes were the occurrence of early per-operative or post-operative complications and the development of de novo stress urinary incontinence. Here, 466 patients were included in the study (382 in the UpholdTM group and 84 in the anterior sacrospinous ligament fixation group). The failure rate at 2 months was 6.0% (5 out of 84) for anterior sacrospinous ligament fixation and 1.3% (5 out of 382) for UpholdTM (p < 0.01). The prevalence of acute urinary retention was significantly lower in the anterior sacrospinous ligament fixation group (3.6%) than in the UpholdTM group (14.1%; p < 0.01), as was the de novo stress urinary incontinence rate (11.9% vs. 33.8%, respectively; p < 0.01). Anterior sacrospinous ligament fixation appears to be an effective, safe alternative to mesh insertion in the management of cystocele via the vaginal approach; the early complication rate was slightly lower, but the early failure rate was slightly higher.

Long-Term Assessment of Pelvic Organ Prolapse Reoperation Risk in Obese Women: Vaginal and Laparoscopic Approaches.

The aim of this study was to compare reoperation risks after pelvic organ prolapse repair at 5-year follow-up between obese, overweight, and normal-weight women and to assess these risks accounting for the surgical procedure. We performed a retrospective chart review of all the women who underwent POP repair by transvaginal mesh surgery between January 2005 and January 2009 or laparoscopic sacrocolpopexy between January 2003 and December 2013 at the Gynecologic Surgery Department of the Lille University Hospital. During the study period, 744 women who underwent POP repair were divided into three groups: 382 (51%), 240 (32%), and 122 (16%) in the nonobese group (BMI < 25 kg/m²), overweight group (25 kg/m² ≤ BMI < 30 kg/m²), and obese group (BMI ≥ 30 kg/m²), respectively. The primary outcome was global reoperation. The median duration of follow-up was 87 months. The risks of global reoperation did not significantly differ between the three BMI groups (adjusted HR (95% CI): 1.12 (0.69 to 1.82) for overweight women and 0.90 (0.46 to 1.74) for obese women compared to normal-weight women, adjusted p = 0.80), nor among the women who underwent transvaginal mesh surgery or laparoscopic sacrocolpopexy. The risks of reoperation for POP recurrence, stress urinary incontinence, or mesh-related complications did not significantly differ between the three BMI groups in the overall population nor accounting for the surgical procedure. In conclusion, obesity does not seem to be a risk factor of reoperation for POP recurrence, SUI, or mesh-related complications in the long term regardless of the surgical approach.

Long-Term Outcomes after Pelvic Organ Prolapse Repair in Young Women.

The aim of the study was to describe the long-term outcomes of Pelvis Organ Prolapse (POP) repair in women under 40 years old. A retrospective chart review of all POP repairs performed in women ≤40 years old between January 1997 and December 2015 in the Gynecologic Surgery Department of Lille University Hospital was performed. Inclusion criteria were all women ≤40 years old who underwent a POP repair with a stage ≥2 POP according to the Baden and Walker classification. The study population was separated into three groups: a sacrohysteropexy group, a vaginal native tissue repair (NTR) group, and a transvaginal mesh surgery (VMS) group. The primary outcome was reoperation procedures for a symptomatic recurrent POP. Secondary outcomes were other complications. During the study period, 43 women ≤ 40 years old who underwent a POP repair were included and separated into three groups: 28 patients (68%), 8 patients (19%), and 7 patients (16%) in the sacrohysteropexy, VMS, and NTR groups respectively. The mean followup time was 83 ± 52 months. POP recurrence, reoperated or not, was essentially diagnosed in the VMS group (87.5%) and the NTR group (50%). POP recurrence repairs were performed for nine patients (21%): 7%, 62.5%, and 25% in the sacrohysteropexy, VMS, and NTR groups, respectively. Global reoperation concerned 10 patients (23%) whatever the type of POP surgery, mainly patients from the VMS group (75%) and from the NTR group (25%). It occurred in only 7% of patients from the sacrohysteropexy group. Two patients (4%) presented a vaginal exposure of the mesh (in the VMS group). De novo stress urinary incontinence was encountered by nine patients (21%): 29% and 12.5% in the sacrohysteropexy and NTR groups, respectively. Despite the risk of recurrence, POP repair should be proposed to young women in order to restore their quality of life. Vaginal native tissue repair or sacrohysteropexy should be performed after explaining to women the advantages and disadvantages of each procedure.

Operative Technique and Experience of One Referral Center With Vaginal Cesarean Delivery.

BACKGROUND: To report the experience of vaginal cesarean delivery and describe the surgical technique. METHOD: This is a retrospective case series from one referral center of patients who underwent vaginal cesarean delivery from 2000 to 2017, presenting a step-by-step operative technique with a video. The operative technique consists of: 1) development of a transvaginal bladder flap by dissecting the bladder off the cervix, thereby exposing the lower uterine segment; 2) making a vertical segment incision up to the highest part of the lower uterine segment, just below the muscular portion of the uterus; 3) extraction of the fetus; and 4) reconstruction of the lower uterine segment and vagina. EXPERIENCE: Seven patients with maternal indications for urgent premature delivery who underwent vaginal cesarean delivery were included. Indications were severe bleeding (n=3), severe previable preeclampsia (n=2), severe heart failure (n=1), and stroke (n=1). The average gestational age at delivery was 21 2/7 weeks (18 2/7-24 1/7 weeks); median fetal birth weight was 300 g (179-500 g). There were no intraoperative complications attributable to the procedure. CONCLUSION: Vaginal cesarean delivery is a valuable technique for rapid fetal extraction of deceased or nonviable fetuses for severe maternal indications.

Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study.

OBJECTIVE: To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy. RESULTS: Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP. CONCLUSIONS: Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.