Comparison of perioperative outcomes between colpocleisis with hysterectomy and colpocleisis without hysterectomy.

STUDY OBJECTIVE: To evaluate the effect of concomitant hysterectomy on perioperative outcomes in patients who underwent obliterative pelvic organ prolapse (POP) surgery. MATERIAL AND METHODS: This retrospective study included 95 consecutive patients with no prior hysterectomy who underwent obliterative surgery for POP between February 2015 and April 2021. Perioperative outcomes of colpocleisis without hysterectomy (C) and colpocleisis with hysterectomy (CH) were compared. RESULTS: Of the 95 patients, 49 (51.6%) underwent C and 46 (48.4%) underwent CH. Patient characteristics including age, body mass index and history of prolapse surgery were comparable between the groups (P-values .367, .199, and .363, respectively). The rate per prolapse stage, from stage 2 to stage 4, was similar in both groups (P-values .709, >.999, and .838 for Stage 2, Stage 3, and Stage 4, respectively). The mean operating time was shorter in the C group than in the CH group (68.9 ± 25.7 minutes versus 94.7 ± 23.1 minutes, P-value < .001). Other perioperative outcomes including postoperative hemoglobin drop, duration of Foley catheter, rate of intraoperative complications, rate of patients with postoperative adverse events, reintervention rate and readmission rate were comparable in both groups (P-values .125, .362, .484, > .999, .495, and > .999, respectively). CONCLUSION: CH is associated with a longer operative time compared to C. However, concomitant hysterectomy does not appear to affect perioperative outcomes other than the operative time negatively.

Vaginal approach versus laparoscopy for hysterectomy in transgender men.

STUDY OBJECTIVE: To describe a vaginal approach combining vaginal hysterectomy (VH) with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) bilateral salpingo-oophorectomy (BSO) for hysterectomy in transgender men and to evaluate the feasibility, safety, and surgical outcomes of this approach in comparison with laparoscopy. MATERIAL AND METHODS: Retrospective cohort study comparing outcomes of the vaginal approach (n = 45) and laparoscopy (n = 45) in transgender men undergoing hysterectomy between May 2017 and June 2020. RESULTS: There was one intraoperative complication (bladder injury) in the laparoscopy group, which was the reason for the only conversion from the initial surgical approach. All vaginal procedures were completed without any intraoperative complications or conversions. Patients in the vaginal approach group had shorter operative times compared to the laparoscopy group (median 60 [range, 30-130] vs median 85 [range, 63-179] minutes; P < 0.001). One patient in the vaginal approach group experienced late-onset intraabdominal bleeding and underwent reoperation on postoperative day 4 after failed expectant management. There were no reoperations in the laparoscopy group. Patients in the vaginal approach group experienced less pain at postoperative 12 h and 24 h (P values < 0.001 and < 0.001, respectively). Postoperative hospital stay was shorter in the vaginal approach group than in the laparoscopy group (median 2 [range, 1-7] vs. median 2 [range, 2-6] days; P < 0.001). There were no readmissions within 30 days after surgery in either group. CONCLUSION: The vaginal approach combining VH with vNOTES BSO is a feasible and safe alternative to laparoscopy for hysterectomy in transgender men.

Impact of transvaginal natural orifice transluminal endoscopic surgery on hysterectomy practice.

STUDY OBJECTIVE: To evaluate the impacts of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) on the hysterectomy route and concomitant adnexal surgery at the time of vaginal hysterectomy (VH). MATERIAL AND METHODS: This retrospective study analyzed all hysterectomies performed for benign indications between 1 January 2017 and 31 December 2019. The period preceding the first case of VH and vNOTES BSO was considered as Pre-vNOTES. The period starting from the date of the first case was considered as Post-vNOTES. The rates per route of hysterectomy and the rate of concomitant adnexal surgery at the time of VH were compared between the two periods. RESULTS: In hysterectomies performed by surgeons who implemented vNOTES, the proportion of the vaginal route increased from 40.1% to 94.3% (P-value < 0.001); the abdominal route decreased from 37.4% to 3.2% (P-value < 0.001); and the laparoscopic route decreased from 22.5% to 2.5% (P-value < 0.001). The rates of concomitant adnexal procedures performed at the time of VH also showed significant changes. While 39.7% of patients did not undergo any concomitant adnexal surgery during the Pre-vNOTES period, this rate dropped to 8.1% after the implementation of vNOTES (P-value < 0.001). Similarly, the rate of bilateral salpingectomy dropped from 49.3% to 14.2% (P-value < 0.001), whereas the rate of BSO increased from 6.8% to 75% (P-value < 0.001). CONCLUSION: Implementation of vNOTES has led to a significant increase in the rate of VH and the rate of concomitant BSO at the time of VH.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Stump Pregnancy.

OBJECTIVE: To demonstrate a case of left tubal stump pregnancy successfully treated using our 2-step technique for transvaginal natural orifice transluminal endoscopic surgery (vNOTES). DESIGN: Demonstration of the technique using surgical video footage. SETTING: Tertiary university hospital. INTERVENTIONS: A 27-year-old gravida 3 para 0 patient with a history of laparotomy, left salpingectomy owing to a ruptured tubal pregnancy, was referred to our hospital because of a pregnancy of unknown location. Her serum ß human chorionic gonadotropin level was 8400 U/L, and a transvaginal ultrasound revealed an ectopic pregnancy in the left tubal stump. After discussing medical and surgical treatment options, the patient underwent a 2-step vNOTES approach. First, a diagnostic vNOTES was performed using a 5-mm trocar with autoretracting blade. After confirmation of the diagnosis, the trocar was removed, and the incision was enlarged with blunt dissection. A self-constructed pessary port was then placed through the enlarged colpotomy, and the ectopic pregnancy in the left tubal stump was excised using an advanced bipolar device. The colpotomy was closed with running resorbable sutures. The duration of the surgery was 36 minutes, and the patient was discharged on postoperative day 1 without any complications. CONCLUSION: Tubal stump pregnancy is a rare form of ectopic pregnancy with an incidence of approximately 0.4% of all ectopic pregnancies [1]. Treatment options include conservative medical management using methotrexate and surgery. Successful surgical treatment using laparoscopy has been previously reported [1,2]. This case demonstrates that vNOTES may be a minimally invasive option for the surgical treatment of tubal stump pregnancy in selected cases.

Simplified two-step technique for transvaginal natural orifice transluminal endoscopic surgery.

OBJECTIVE: To describe our simplified two-step technique for transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and to demonstrate the application of the technique. DESIGN: Step-by-step description of the technique and demonstration of its application using surgical video footage from two different cases. SETTING: Tertiary university hospital. PATIENT(S): Patient 1 was a 27-year-old G0P0 woman who presented with right lower quadrant pain. Transvaginal ultrasound scan revealed a right ovarian torsion. Patient 2 was a 25-year-old G3P2 woman. She presented with vaginal bleeding and left lower quadrant pain. Her serum ß-human chorionic gonadotropin level was 28,313 U/L, and transvaginal ultrasound scan revealed an ectopic pregnancy in the left tube. The decision to perform vNOTES was made for both patients. INTERVENTION(S): As the first step, patients underwent diagnostic vNOTES. The patient was placed in lithotomy position under general anesthesia. By use of a 5-mm trocar with autoretracting blade, a colpotomy was performed on the posterior vaginal wall. Pneumoperitoneum was achieved, and the patient was placed in a Trendelenburg position. A 5-mm 30° rigid endoscope was introduced, and the diagnosis was confirmed. After the confirmation of the diagnosis, we proceeded to the second step. The colpotomy was enlarged with blunt dissection by using Metzenbaum scissors. A self-constructed pessary port was placed through the colpotomy, and pneumoperitoneum was achieved. The therapeutic procedure was then performed. Patient 1 underwent ovarian detorsion with a 5-mm laparoscopic grasper. After the ovary was detorsioned, a 5-mm bipolar instrument was used to achieve hemostasis. Patient 2 underwent left salpingectomy with a 5-mm advanced bipolar device. Hemostasis was verified, and the specimen was extracted through the colpotomy. Procedures ended with the closure of colpotomy with running resorbable sutures. MAIN OUTCOME MEASURE(S): Description of the technique and demonstration of its applicability in two common gynecological emergencies. RESULT(S): Both patients were treated successfully by vNOTES. The operating times were 25 minutes and 38 minutes for patient 1 and patient 2, respectively. Patients were discharged on postoperative day 1 without any complications. CONCLUSION(S): Our simplified two-step technique described and demonstrated in this video article is a feasible and practical approach to perform vNOTES. The first step allows the confirmation of the diagnosis and facilitates the colpotomy. The use of the self-constructed pessary port enables to perform surgery with already existing equipment without the need for specialized equipment and without increasing the costs.

Is overactive bladder microvasculature disease a component of systemic atheroscleorosis?

AIMS: To evaluate the relationship between overactive bladder (OAB) and systemic atherosclerosis in a cohort of women. METHODS: In this case-control study, we assessed atherosclerosis indicators, such as Framingham risk scores and carotid and femoral artery intima-media thickness, and evaluated possible bladder wall responses to atherosclerosis using endovaginal color Doppler ultrasound and the detection of urinary cytokines in women with OAB and in controls. Quantitative assessment of blood perfusion at the bladder neck was performed using a method that allows for the dynamic monitoring of flow in a predefined region of interest at every point of the cardiac cycle. The independent samples t-test was used to evaluate the relationship between OAB and the atherosclerotic findings when parametric conditions were met, and the Mann-Whitney U test was used when parametric conditions were not met. Kendall's Tau was used to assess the correlation between OAB severity and the atherosclerotic variables. P < 0.05 was considered statistically significant. RESULTS: There were 74 OAB patients and 73 controls; in total, 147 women were evaluated. We found that all atherosclerosis indicators were significantly associated with OAB and that there was a significant relationship between OAB and decreased bladder neck perfusion. Additionally, there were correlations of OAB severity with systemic atherosclerosis and impaired vascular perfusion of the bladder. CONCLUSIONS: Decreased perfusion at the bladder neck, the Framingham scores in severe OAB, and the correlation between them suggest that OAB microvascular disease may be a component of systemic atherosclerosis rather than a separate process.

Systemic atherosclerosis and voiding symptom.

OBJECTIVE: To evaluate the effect of atherosclerosis on the storage and voiding symptoms of the bladder in women with overactive bladder (OAB). STUDY DESIGN: We retrospectively reviewed the charts of women with OAB who were evaluated between 2013 and 2015 in our urogynecology unit. Charts were assessed for history, examination findings, urinary diary, quality of life (QOL) questionnaires, urodynamic studies (UDSs), and four main risk factors for atherosclerosis: hypertension, diabetes mellitus, smoking, and hyperlipidemia. In a previous study, these were defined as vascular risk factors. Cases were excluded for insufficient data, diabetes mellitus with dysregulated blood glucose, or prolapse greater than 1cm to avoid confusing bladder outlet obstruction. We included 167 eligible cases in this study. We evaluated storage and voiding symptoms such as frequency, nocturia, residual urine volume, and voiding difficulties and UDS findings such as maximum bladder capacity, first desire, strong desire, detrusor overactivity, and bladder contractility index. The vascular risk score was categorized as "no risk" if the woman did not have any of the four risk factors and "at risk" if she had any of the factors. Independent sample t-test and chi-square tests were performed for analyses. RESULTS: Among the participants (n=167), 71.9% had at least one vascular risk factor. Those who were at risk were facing significantly more wet-type OAB (p=0.003) and nocturia (p=0.023). Moreover, mean age (p=0.008) and mean gravidity (p=0.020) were significantly higher in the at-risk group, whereas mean total nocturia QOL questionnaire scores (p=0.029) were significantly lower. CONCLUSION: Our findings suggest that aging and atherosclerosis may be associated with severe OAB and poorer QOL. Nocturia and related parameters of poor quality can be explained by impaired bladder neck perfusion. Future trials need to assess vascular and molecular changes in women with OAB.

Do stages of menopause affect the outcomes of pelvic floor muscle training?

OBJECTIVE: The purpose of our study is to determine whether there is a difference in pelvic floor muscle strength attributable to pelvic floor muscle training conducted during different stages of menopause. METHODS: One hundred twenty-two women with stress urinary incontinence and mixed urinary incontinence were included in this prospective controlled study. The participants included in this study were separated into three groups according to the Stages of Reproductive Aging Workshop staging system as follows: group 1 (n = 41): stages -3 and -2; group 2 (n = 32): stages +1 and -1; and group 3 (n = 30): stage +2. All three groups were provided an individual home exercise program throughout the 12-week study. Pelvic floor muscle strength before and after the 12-week treatment was measured in all participants (using the PERFECT [power, endurance, number of repetitions, and number of fast (1-s) contractions; every contraction is timed] scheme, perineometry, transabdominal ultrasound, Brink scale, pad test, and stop test). Data were analyzed using analysis of variance. RESULTS: There were no statistically significant differences in pre-exercise training pelvic floor muscle strength parameters among the three groups. After 12 weeks, there were statistically significant increases in PERFECT scheme, Brink scale, perineometry, and ultrasound values. In contrast, there were significant decreases in stop test and 1-hour pad test values observed in the three groups (P = 0.001, dependent t test). In comparison with the other groups, group 1 demonstrated statistically significant improvements in the following postexercise training parameters: power, repetition, speed, Brink vertical displacement, and stop test. The lowest increase was observed in group 2 (P < 0.05). CONCLUSIONS: Strength increase can be achieved at all stages of menopause with pelvic floor muscle training, but the rates of increase vary according to the menopausal stage of the participants. Women in the late menopausal transition and early menopause are least responsive to pelvic floor muscle strength training. Further studies in this field are needed.

Overactive bladder and its effects on sexual dysfunction among women.

OBJECTIVE: To evaluate the relation between overactive bladder (OAB) and sexual dysfunction in sexually active nurses without stress urinary incontinence and pelvic organ prolapse. DESIGN: Prospective, observational study. SETTING: Tertiary care center. POPULATION: 200 nurses, under 49 years of age. METHOD: Data were obtained with Turkish language-validated questionnaires between January 2011 and June 2011. OAB was diagnosed using the Overactive Bladder Awareness Tool (OAB AT). MAIN OUTCOME MEASURES: Scores on the Overactive Bladder Symptom and Health-related Quality of Life Questionnaire Short Form (OABq-SF), the Health-related Quality of Life Questionnaire Short Form (HRQOL), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form (PISQ-12). RESULTS: Of the 127 enrolled volunteers, 51 were diagnosed with OAB. The mean age of the participants was 37.8 ± 7.3 years. After controlling for age, body mass index, and parity, OAB did not significantly affect PISQ-12 scores, but significantly worsened OABq-SF scores. No strong correlation was noted between the parts of the OABq-SF and the domains of the PISQ-12. CONCLUSION: OAB is a common problem among sexually active young women and significantly affects their quality of life. However, OAB-related sexual dysfunction plays a limited role among sexually active nurses.

How do delivery mode and parity affect pelvic organ prolapse?

OBJECTIVE: To determine the association between mode of delivery, parity, and pelvic organ prolapse, as assessed by the pelvic organ prolapse quantification system. DESIGN: Cross-sectional study. SETTING: Tertiary referral center, Turkey. POPULATION: A total of 1964 women with benign gynecological disorders who presented between October 2009 and July 2011. METHODS: Evaluation using the pelvic organ prolapse quantification system and questionnaire assessing previous obstetrics and medical history. MAIN OUTCOME MEASURES: Difference in pelvic organ prolapse stages between nulliparous and multiparous women, impact of parity and mode of delivery. RESULTS: In the study population, 86.4, 7.2 and 6.4% had pelvic organ prolapse of stages 0-I, II, and III-IV, respectively, and 7.9% had significant prolapse beyond the hymen. The mean age, parity, and number of vaginal deliveries were significantly higher in the prolapse than in the non-prolapse group. Vaginal delivery was associated with an odds ratio of 2.92 (95% confidence interval 1.19-7.17) for prolapse when compared with nulliparity. Each vaginal delivery increased the risk of prolapse (odds ratio 1.23; 95% confidence interval 1.12-1.35) after controlling for all confounding factors. Cesarean delivery had no impact on the odds for prolapse. CONCLUSIONS: Vaginal delivery was an independent risk factor for prolapse, and additional vaginal deliveries significantly increased the risk. However, cesarean delivery had no effect on the development of prolapse in this material.

Quality of life scores improve in women undergoing colpocleisis: a pilot study.

OBJECTIVE: To evaluate the quality of life and surgical outcomes in women who had undergone colpocleisis. STUDY DESIGN: This was a prospective small cohort study conducted between August 2010 and September 2011. Twelve women with pelvic organ prolapse were offered obliterative vaginal surgery and were informed about the surgical procedure. Ten women accepted this operation and were included in the study. Before and after colpocleisis, cases were evaluated by urogynecological examination, and quality of life was assessed by the Turkish language validated prolapse quality of life questionnaire (P-QOL), in which a low total score indicates a good quality of life. RESULTS: The mean age was 74.9±4.5 (range 68-85). The general score of the P-QOL was reduced during the follow-up period, reflecting a significant effect on quality of life and clinical improvement in women with the colpocleisis operation. There was no morbidity due to colpocleisis or recurrent pelvic organ prolapse in follow-up period. CONCLUSION: In our small cohort including elderly women, colpocleisis provided high levels of surgical outcomes as well as a significant improvement in quality of life without significant morbidity.

Effect of placenta previa on fetal growth restriction and stillbirth.

AIM: To examine the association between placenta previa and adverse perinatal outcomes such as low birth weight, preterm delivery, stillbirth and fetal growth restriction (FGR). METHODS: This retrospective cohort study includes 12,034 delivered pregnant women who were recruited for the study between 2004 and 2010 in Ege University Hospital. Data were collected by browsing the clinic's archives. The association between placenta previa and adverse perinatal outcomes was determined via Chi-square tests and Student's t test. Logistic regression analysis was used to adjust for confounding factors in evaluating the association between placenta previa and the adverse perinatal outcomes. RESULTS: There was no significant relationship between placenta previa and FGR or stillbirth. Low birth weight and preterm delivery were significantly higher in the placenta previa group. According to logistic regression analysis, low birth weight was associated with an OR of 3.01 (95 % CI 2.05-4.52) and preterm delivery was associated with an OR of 8.14 (95 % CI 5.60-11.83); while, placenta previa did not affect FGR and stillbirth significantly. CONCLUSION: Although there is no consensus on the association between placenta previa and FGR in previous studies, we suggest that placenta previa is not a reason for placental insufficiency. Management of placenta previa especially depends on maternal hemodynamic parameters such as heavy hemorrhage and hypotensive shock rather than fetal well-being protocols based on serial growth ultrasound and fetal Doppler investigation.

How frequent are overactive bladder symptoms in women with urodynamic verification of an overactive bladder?

OBJECTIVE: To determine the relationship between overactive bladder symptoms and urodynamic verification of overactive bladder. MATERIAL AND METHODS: Between June 2011 and November 2011, 159 patients underwent urodynamics (UDS) at our urogynecology unit in the Ege University Hospital. Of these, 95 patients who complained of urgency, did not have any overt neurological diseases, bladder outlet obstruction and did not take any medication affecting the lower urinary tract function were evaluated. SPSS (ver. 15.0) was used to evaluate the data and the chi-square test and t test for independent samples were used for analysis. RESULTS: The mean age was found to be 54.5±12. Frequency was the most frequent symptom in women with overactive bladder (OAB) (82.1%), nocturia (57.8%) and (57.8%) urgency urinary incontinence followed in frequency. Detrusor over activity incidence was found to be 38.9%. There was no significant relationship between the presence of detrusor over activity (DOA) and OAB symptoms. Leak at urodynamics was found in 46.3% and there is no significant association with detrusor overactivity. Total bladder capacity was found to be significantly lower in women who had DOA (p=0.000). CONCLUSION: It appears that overactive bladder symptoms do not predict detrusor over activity. Urodynamic investigation is not mandatory in the initial management of women with only OAB symptoms.

Effect of BCG vaccine on peritoneal endometriotic implants in a rat model of endometriosis.

OBJECTIVE: To investigate the effect of Bacillus Calmette-Guerin (BCG) vaccine on peritoneal implantation of endometrial tissue in rats. METHODS: Forty sexually mature virgin Wistar albino rats weighing 190-200 g were randomly assigned (double blind) to two groups. The rats in the first group were vaccinated with 0.1 mL BCG and those in the second group were injected with 0.1 mL saline into the tail, intracutaneously. All the rats underwent median laparotomy after 4 weeks of vaccination or injection. The right uterine horn was excised, and the two samples of endometrial tissue dissected from myometrium were implanted on each side of peritoneum at the 2 cm lateral line of the median laparotomy incision. The implanted peritoneal segments were excised after 8 weeks of laparotomy. The tissue samples were accepted, histologically, as endometriosis when both glands and stroma of endometrial tissue were seen in sections. RESULTS: Thirty-six implants from the study group and 34 implants from the control group were obtained. Ten and 23 implants were accepted as endometriosis in the study and control group, respectively. The number of endometriotic foci were significantly lower in the study group than in the control group (P = 0.01). CONCLUSIONS: Stimulation of the cellular immune response with BCG vaccine could exert an inhibitory effect on ectopic endometriotic implants.

The changes of circulating lymphocyte sub-populations in women with preterm labour: a case-controlled study.

OBJECTIVE: The aim of this study was to determine the changes in circulating T-cell subpopulations, B cells and natural killer cells in patients with imminent preterm labour. METHODS: Thirty-five pregnant patients with imminent preterm labour and 35 women with uncomplicated pregnancies were included in the study. The gestational ages of the patients ranged from 28 to 36 weeks in both groups. The specific lymphocyte antigens were detected using direct staining with monoclonal antibodies, and analysed by flow cytometry. RESULTS: We observed no significant difference in the mean percentage of T cell subpopulations, natural killer cells and active T cells in the group of patients with preterm labor when compared to controls. The mean percentage of T CD3+ lymphocytes was significantly lower and that of B CD19+ cells higher in the study group when compared to controls. CONCLUSION: The alterations in maternal circulating lymphocyte subpopulations could be associated with the mechanisms mediating preterm labour.