A Retrospective Cohort Study of vNOTES Extraperitoneal Versus Laparoscopic Sacral Hysteropexy With Uterine Preserving Regarding Surgical Outcomes and Two-Year Follow-Up Results.

STUDY OBJECTIVE: To explore the effectiveness of transvaginal natural orifice transluminal endoscopic surgery extraperitoneal sacral hysteropexy (vNOTES-ESH) in women with symptomatic uterine prolapse over a 2 year follow-up. DESIGN: Retrospective cohort study. SETTING: Gynecological minimally invasive center. PATIENTS: Women undergoing sacral hysteropexy either by vNOTES (n = 25) or laparoscopic (n = 74) between November 2016 and December 2020. INTERVENTIONS: Both vNOTES-ESH and laparoscopic sacral hysteropexy (LAP-SH) were used for uterine prolapse. Demographic data, operative characteristics, perioperative outcomes, and follow-up information 2 years postsurgery in the 2 groups were retrospectively evaluated. RESULTS: Both procedures showed similar operation time, estimated blood loss, hospital stays, and pain scores (p >0.05). During a median follow-up of 59 (24-72) months, the surgical success rate was 96% for vNOTES-ESH and 97.3% for LAP-SH (p >0.05), with no differences in anatomical position or pelvic organ function after the operation. Women in the LAP-SH group experienced more bothersome symptoms of constipation compared to those in the vNOTES-ESH group (5.41% vs 0, p <0.05). Lastly, 1 case in the vNOTES-ESH group had a mesh exposed area of less than 1 cm2, and 1 patient in the LAP-SH group experienced stress incontinence. CONCLUSIONS: In this retrospective study, vNOTES-ESH met our patients' preference for uterine preservation and was a successful and effective treatment for uterine prolapse, providing good functional improvement in our follow-up. This procedure should be considered as an option for patients with pelvic organ prolapse.

Long-term outcome and risk factors of reintervention after high intensity focused ultrasound ablation for uterine fibroids: a systematic review and meta-analysis.

OBJECTIVES: To quantify the reintervention rate and analyze the risk factors for reintervention after high-intensity focused ultrasound (HIFU) ablation of uterine fibroids. METHODS: Eighteen studies were selected from the seven databases. A meta-analysis was applied to synthesize the reintervention rates for fibroids across various follow-up durations. Subgroup-analysis was conducted based on the year of surgery, sample size, guide methods, and non-perfusion volume ratio (NPVR). Signal intensity of T2-weighted imaging (T2WI) was independently evaluated for reintervention risk. RESULTS: The study enrolled 5216 patients with fibroids treated with HIFU. There were 3247, 1239, 1762, and 2535 women reaching reintervention rates of 1% (95% confidence interval (CI): 1-1), 7% (95% CI: 4-11), 19% (95% CI: 11-27), and 29% (95% CI: 14-44) at 12, 24, 36, and 60-month after HIFU. The reintervention rates of patients treated with US-guided HIFU (USgHIFU) were significantly lower than those of patients treated with MR-guided focused ultrasound surgery (MRgFUS). When the NPVR of fibroids was over 50%, the reintervention rates at 12, 36 and 60-month after HIFU were 1% (95% CI: 0.3-2), 5% (95% CI: 3-8), and 15% (95% CI: 9-20). The reintervention risk for hyper-intensity fibroids on T2WI was 3.45 times higher (95% CI: 2.7-4.39) for hypo-/iso-intensity fibroids. CONCLUSION: This meta-analysis showed that the overall reintervention rates after HIFU were acceptable and provided consultative suggestions regarding treatment alternatives for patients with fibroids. Subgroup-analysis revealed that USgHIFU, NPVR ≥ 50%, and hypo-/iso-intensity of fibroids on T2WI were significant factors in reducing reintervention. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42023456094.

The efficacy of ureteroscopic triage in increasing the cure rate of the first-line treatment for a ureterovaginal fistula resulting from radical hysterectomy.

Study objective: To explore the effect of pretreatment with ureteroscopic triage for iatrogenic ureterovaginal fistula (UVF) resulting from radical hysterectomy. Design: A retrospective cohort study. Setting: Department of gynecology at a tertiary medical center. Patients: Women diagnosed with UVF secondary to radical hysterectomy at our center between April 2008 to June 2018. Interventions: The patients were divided into two groups according to whether pretreatment with ureteroscopic triage was performed. Those in the non-triage group underwent retrograde placement of a double-J stent immediately following diagnosis as the first-line therapy. Patients in the triage group were first evaluated under ureteroscopy, their ureteral injuries were then classified into different grades and then underwent different treatments as the first-line therapy, including stent placement or reconstruction surgeries. The cure rate of the first-line therapy and the timeliness of the implementation of adjuvant radiotherapy were subsequently analyzed. Measurements and main results: Ninety-eight UVF patients were included. The demographics, ECOG status, stage of cervical cancer (FIGO 2009), types and onset time of symptoms were not different between the two groups. There were 54 patients in the nontriage group, with an overall first-line cure rate of 70.4% and a timely implementation rate of adjuvant radiotherapy of 38.5%. There were 44 patients in the evaluation group, with an overall first-line cure rate of 93.2% and a timely implementation rate of adjuvant radiotherapy of 90.0%. The differences were statistically significant (p < 0.001). Conclusion: Ureteroscopic triage of ureteral injuries can guide the selection of the optimal first-line therapy for patients with UVF secondary to radical hysterectomy, increase the cure rate and ensure the timely implementation of adjuvant radiotherapy.

Anatomical variations, treatment and outcomes of Herlyn-Werner-Wunderlich syndrome: a literature review of 1673 cases.

PURPOSE: This study aimed to perform a systematic review of patients with Herlyn-Werner-Wunderlich syndrome (HWWS) and present the prevalence of symptoms, anatomical variants, endometriosis, surgical interventions, and short- and long-term outcomes. METHODS: A structured search was performed in PubMed, Scopus, Embase, and China National Knowledge Infrastructure, and studies published between 1 January, 2000 and 19 April, 2022 were included. The following data on HWWS were recorded: symptoms, anatomical variations, surgical interventions and short- and long-term outcomes. RESULTS: A total of 1673 patients were included in our analysis. The main symptoms were dysmenorrhea (53.8%), abnormal uterine bleeding (28.9%), and vaginal discharge (26.6%). The principal anomalies were right-obstructed hemivagina (57.3%), haematocolpos (81.7%), uterus didelphys (88.8%), and ipsilateral renal agenesis (93.1%). A majority of patients belonged to classification 1.1 (46.7%), with a blind hemivagina, and classification 2.1 (39.2%), with a small communication between two vaginas. The mainstay of treatment was vaginal septum excision (91.8%). Minimally invasive surgery (48.5%) was performed only after vaginal surgery (61.9%), and only a few patients required a second surgery (2.2%). Endometriosis was found in 9.6% of the patients. Fifty-two percent of them had ipsilateral ovarian endometriosis cysts. Pregnancy rate of these patients was 72.1%. The rate of adverse pregnancy outcomes was 22.4%. The caesarean section rate was 61.2%. CONCLUSIONS: Patients with HWWS presented with nonspecific symptoms and demonstrated various combinations of anomalies. The most common anatomical variants are classifications 1.1 and 2.1. Vaginal septum excision is effective in relieving symptoms and preventing complications, with hysteroscopic surgery as an option where there is concern about protecting the hymen from minor injury. The pregnancy rate for these patients after surgery was satisfactory, and the rate of adverse pregnancy outcomes after surgery was acceptable. We advise females with urological anomalies to be screened for Müllerian anomalies because of the close association between these two types of anomalies. Thus, HWWS contributes to the occurrence of endometriosis; however, more research is required to investigate the relationship between pelvic endometriosis and HWWS.

Learning curve for laparoendoscopic single-site radical hysterectomy using the "chopstick" technique: a retrospective cohort study.

Background: Laparoendoscopic single-site surgery (LESS), as a promising minimally invasive surgery, is confronted with the obstacle of the "chopstick effect" which limits its further application. The "chopstick" technique is characterized by the usage of instruments of parallel and equal length, and in operations relying on double-fulcrum and unique surgeon position can play a key role in overcoming the above disadvantage effect. This study sought to explore the learning curve for the use of the novel "chopstick" technique in laparoendoscopic single-site radical hysterectomy (LESS-RH) and evaluate the technique's practicability. Methods: Consecutive cervical cancer patients who underwent LESS-RH with the "chopstick" technique by a surgeon with rich experience in laparoscopy from November 2016 to September 2018 were included in the study. The learning curve of his surgeries with the "chopstick" technique was evaluated using the cumulative summation (CUSUM) method by analyzing operation time (OT) which was the surrogate indicator of surgical ability. The patients were divided into Phase I and Phase II based on the learning curve peak, whose demographic and perioperative characteristics, such as tumor Federation International of Gynecology and Obstetrics (FIGO) stage and histology, operation time, blood loss, and complications were collected and analyzed. Results: The mean OT was 231.5 min (range, 115-355 min). The division of the learning curve based on OT occurred after the first 15 cases were finished, dividing Phase I and Phase II. The mean OT for Phase I (259 min) was significantly longer than that of Phase II (219 min) (P=0.02). Only 1 intraoperative complication occurred in Phase I, and none occurred in Phase II. Major postoperative complications occurred more frequently in Phase I (N=3) than in Phase II (N=0). No significant differences were observed in terms of lymph nodes, blood loss, or pathological features. Conclusions: The "chopstick" technique may help surgeons obtain stable LESS surgical performance through a relatively short learning curve, even in some complex surgeries, such as radical hysterectomy.

Chopstick technique versus cross technique in LESS hysterectomy (CCLEH study): a prospective randomized controlled trial.

BACKGROUND: The traditional cross technique can be used to complete most laparoendoscopic single-site surgery (LESS) procedures, but some relatively precise operations, such as vaginal stump suturing, are challenging. In practice, we have introduced a novel technique named the chopstick technique and applied it to more complex operations, such as cervical cancer operations, and found that it contributes to performing delicate surgery. The efficacy and safety of two different surgical techniques in LESS hysterectomy remain to be validated. METHODS: Patients who undergo total hysterectomy will be enrolled in this RCT. Stratified randomization will be performed according to uterine size (< 10 cm, 10-15cm, ≥ 15 cm). The participants will be divided into the chopstick technique group or cross technique group to undergo laparoendoscopic single-site total hysterectomy (LESS-TH), and then the perioperative and postoperative data, including the total operation time and other times, transfer rates, estimated blood loss, surgeon fatigue, intraoperative and postoperative complications (within 8 weeks after surgery), health-related quality of life (EQ-5D) scores, postoperative hospital stay, and hospitalization expenses, will be evaluated. The primary outcome is the operating time for total hysterectomy under LESS, and the other outcomes are secondary outcomes. DISCUSSION: It is expected that the efficacy of the two techniques in LESS, the chopstick technique vs. the cross technique, will be compared and accumulate safety data on the new techniques will be accumulated. TRIAL REGISTRATION: ChiCTR2000040843, registered on June 16,2020 Protocol version: Version 2.0; Date: 2020.05.10.

Short- and Long-term Outcomes of Postoperative Intrauterine Application of Hyaluronic Acid Gel: A Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To systematically evaluate the role of hyaluronic acid (HA) gel and its derivatives in the postoperative prevention of intrauterine adhesions (IUA) and to assess whether HA gel could improve the pregnancy rate. DATA SOURCES: A structured search was performed in PubMed, Cochrane, Scopus, Web of Science, and Embase on February 2, 2022. METHODS OF STUDY SELECTION: We chose medical subject headings and relevant terms from other articles for the database search. The following intervention was selected: HA gel or related derivatives vs placebo in randomized controlled trials (RCTs). The following outcomes were selected: the rate and severity of IUA after intrauterine operations and pregnancy rate. After the full-text screening, 12 articles were included in the final analysis. The study quality and risk of bias were assessed with the Cochrane tool (www.training.cochrane.org/handbook). TABULATION, INTEGRATION, AND RESULTS: Data from 12 articles on 1579 patients were extracted and analyzed by 2 independent reviewers. According to the meta-analysis, HA gel could decrease the risk of IUA (risk ratio [RR], 0.50; 95% confidence interval [CI], 0.37-0.67; p = .005; I2 = 59%) after intrauterine operations. Subgroup analysis revealed a significant positive impact of HA gel on both groups receiving dilatation and curettage (RR, 0.42; 95% CI, 0.30-0.59; p = .86; I2 = 0) or hysteroscopic surgery (RR, 0.55; 95% CI, 0.38-0.80; p = .007; I2 = 66%). The sensitivity analysis showed that heterogeneity could be improved significantly by removing one study. The severity of IUA (mean difference = -0.92; 95% CI, -1.49 to -0.34; p <.00; I2 = 89%) was lower in the intervention group. Subgroup and sensitivity analyses did not significantly improve the heterogeneity. When the studies are classified by the volume of HA gel, 10 mL (RR, 0.40; 95% CI, 0.27-0.60; p = .96; I2 = 0) and 5 mL (RR, 0.34; 95% CI, 0.14-0.82; p = .36; I2 = 0) were effective in treating IUA. In contrast, HA gel <5 mL was not sufficient to prevent IUA (RR, 0.66; 95% CI, 0.43-1.01; p = .02; I2 = 71%; p = .05). The pregnancy rate was also improved by the use of HA gel (RR, 1.39; 95% CI, 1.13-1.72; p = .37, I2 = 0). CONCLUSION: HA gel helps prevent IUA and decreases the severity of IUA after intrauterine surgery. A greater volume (≥5 mL) of HA gel is recommended to prevent IUA, according to this analysis. Moreover, HA gel can increase the pregnancy rate after intrauterine surgery. However, these conclusions should be interpreted with caution because of the inadequate quality of some RCTs with relatively small sample sizes and sample heterogeneity. Large RCTs are required to verify these conclusions in the future.

Chopstick technique used in laparoendoscopic single site radical hysterectomy for early stage cervical cancer.

Laparoendoscopic single-site surgery (LESS) further minimizes the invasiveness of traditional laparoscopic surgery. However, the "chopstick" effect caused by the parallel arrangement of the instruments in the umbilicus is considered an obstacle indelicate operations. The purpose of this study was to introduce a new technique characterized by a double fulcrum formed by instruments, named the "chopstick" technique, which facilitates the expedient accomplishment of complicated surgeries such as LESS radical hysterectomy (LESS-RH). Seventy-three patients who underwent LESS-RH using the "chopstick" technique were retrospectively analyzed. The procedure was performed successfully in 72 patients. The median operative duration was 225 min, and the median intraoperative blood loss was 200 ml. Among the operations in the first 20 patients, intraoperative vascular injuries and bladder injury occurred in two patients and were repaired by LESS. Patients responded positively regarding minimal postoperative pain control. The score of satisfaction with the cosmetic outcome expressed by the patients was eight at discharge and nine 30 days later. In conclusion, this study presents the feasibility of accomplishing complicated procedures, such as radical hysterectomy, by LESS using the "chopstick" technique. This approach provides more options for both selected patients and surgeons.

vNOTES Hysterectomy with Sentinel Lymph Node Mapping for Endometrial Cancer: Description of Technique and Perioperative Outcomes.

STUDY OBJECTIVE: To explore the technique and clinical value of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in hysterectomy and sentinel lymph node (SLN) mapping for endometrial cancer by comparing its perioperative outcomes with those of laparoscopic staging. DESIGN: Retrospective cohort study. SETTING: Department of gynecology at a tertiary medical center. PATIENTS: All women diagnosed with endometrial cancer who underwent minimally invasive surgery at our center between August 2017 and May 2020. INTERVENTIONS: Both vNOTES and laparoscopic approaches were used for hysterectomy and SLN mapping. The success of SLN detection as well as perioperative outcomes were subsequently analyzed. MEASUREMENTS AND MAIN RESULTS: This study included 74 patients; 23 patients underwent vNOTES surgery, whereas 51 underwent standard laparoscopic surgery. The total successful SLN detection was 95.7% in the vNOTES group and 92.2% in the laparoscopy group (p >.05), whereas the bilateral success rates were 87.0% and 90.2%, respectively. No difference in SLN detection was observed between the 2 groups in terms of the side-specific mapping efficacy quotient (91.3% vs 91.2%, p = .47). The number of harvested SLNs, operative time, estimated blood loss, and intraoperative complications in the 2 groups were similar. One (4.3%) postoperative complication occurred in the vNOTES group vs 4 (7.9%) in the laparoscopy group (p = .029), and the median postoperative hospital stay was 3 days vs 4 days (p = .003). CONCLUSION: This study suggests that the vNOTES procedure is feasible, with a potentially decreased postoperative hospital stay, faster recovery, and better cosmetic results. However, prospective research is needed to validate its broader clinical application.

A retrospective analysis on 1901 women with high grade cervical intraepithelial neoplasia by colposcopic biopsy.

OBJECTIVE: Clinically, an unbefitting management for high grade squamous intraepithelial lesion (HSIL) may result from an inaccurate diagnosis by colposcopy bioposy.The study aimed to assess the diagnostic accuracy by colposcopic biopsy and evaluate the associated factors in diagnosing HSIL. STUDY DESIGN: Clinical data of 1901 women who were primarily diagnosed as HSIL by colposcopic biopsy and then underwent definitive surgery within six-month interval in Women's Hospital, School of Medicine, Zhejiang University during 2009-2015, were retrospectively collected. The diagnostic accuracy of HSIL by colposcopic biopsy was assessed and the correlations between diagnostic accuracy and clinic-pathological variables were calculated by univariate and multivariate analysis using the pathological diagnosis by definitive surgery as a reference standard. RESULTS: The accordance rate of HSIL diagnosis between colposcopic biopsy and definitive surgery was 80.6%, with an under-diagnosis rate of 5.8% and an over-diagnosis rate of 13.6%. Cytology≤low grade squamous intraepithelial lesion(LSIL) (OR:1.599;95%CI:1.185-2.160), colposcopy≤LSIL (OR:2.083;95%CI:1.537-2.824), endocervical curettage (ECC)≤LSIL(OR:2.813;95%CI:2.051-3.857), and lesion without gland involved (OR:1.751;95%CI:1.299-2.361) were independent risk factors for over-diagnosis of HSIL. Women with≥3 risk factors had a 5.078-flod higher risk for over-diagnosis of HSIL compared to those with≤1 risk factor. Irregular vaginal bleeding (OR:2.570,95%CI:1.668-3.960), colposcopy=HSIL (OR:1.699,95%CI:1.022-2.824), ECC=HSIL (OR:2.666, 95%CI:1.728-4.113), and multiple biopsies (OR:1.818, 95%CI:1.153-2.868) were independent risk factors for under-diagnosis of HSIL. Women with ≥3 risk factors had a 5.710-flod higher risk for under-diagnosis of HSIL compared to those with ≤1 risk factor. CONCLUSIONS: The diagnostic accuracy of HSIL by colposcopic biopsy is about 80% and associated with some factors including symptom, cytology result, colposcopy diagnosis, and biopsy number. These variables may be predictors for over-diagnosis or under-diagnosis of HSIL by colposcopic biopsy.

Triage for management of cervical high-grade squamous intraepithelial lesion patients with positive margin by conization: a retrospective analysis.

The objective of this study is to guide a triage for the management of cervical high-grade squamous intraepithelial lesion (HSIL) patients with positive margin by conization. Clinico-pathological data of HSIL patients with positive margin by conization were retrospectively collected from January 2009 to December 2014. All patients underwent secondary conization or hysterectomy within 6 months. The rate of residual lesion was calculated, and the factors associated with residual lesion were analyzed by univariate and multivariate analyses. Among a total of 119 patients, 56 (47.06%) patients presented residual HSIL in their subsequent surgical specimens, including 4 cases of invasive cervical carcinoma (3 stage IA1 and 1 stage IA2 patients). Univariate analysis showed that patient age > 35 years (P = 0.005), menopausal period > 5 years (P = 0.0035), and multiple-quadrant involvement (P = 0.001) were significantly correlated with residual disease; however, multivariate analysis revealed that multiple-quadrant involvement (P = 0.001; OR, 3.701; 95%CI, 1.496-9.154) was an independent risk factor for residual disease. Nearly half of HSIL patients with positive margin by conization were disease-free in subsequent surgical specimens, and those with multiple positive margins may consider reconization or re-assessment.