Implementation of French AmbUlatory Cesarean Section (FAUCS): Establishment of a Learning Curve and Short-term Outcomes.

BACKGROUND: The French AmbUlatory Cesarean Section (FAUCS) technique was introduced to the Galilee Medical Center in September 2021. FAUCS was performed electively for interested women who meet the criteria. OBJECTIVES: To evaluate the learning curve of senior surgeons performing FAUCS, the procedure short-term outcomes, and complications. METHODS: This retrospective study included 50 consecutive women who underwent FAUCS from September 2021 until March 2022 at our facility. Preoperative, intraoperative, postoperative, and demographic data were retrieved from patient electronic charts. RESULTS: The mean duration of surgery was 53.26 ± 11.62 minutes. This time decreased as the surgical team's experience increased: from a mean 58.26 ± 12.25 minutes for the first 15 procedures to a mean 51.17 ± 9.73 minutes for subsequent procedures. The mean visual analogue scale score for 24 hours was 1.08 ± 0.84 (on a 10-point scale). The rate of neonatal cord pH < 7.2 was 6%, and there were 11.3% cases of vacuum assisted fetal extraction. In total, 44% of the women were able to mobilize and urinate spontaneously by 4-6 hours. Complications included bladder injury (n=1), endometritis (n=1), and incisional hematoma (n=1). Overall, the maternal satisfaction rate was high; 94% of the women would recommend FAUCS to others. CONCLUSIONS: FAUCS is a feasible procedure with a high satisfaction rate. Following the first 15 procedures performed by one surgical team, the operative time decreased considerably. Further randomized controlled studies are needed to compare this procedure to regular cesarean section and evaluate neonatal outcomes.

Maternal and Cord Anti-SARS-CoV-2-Spike IgG following COVID-19 Vaccination versus Infection during Pregnancy: A Prospective Study, Israel October 2021-March 2022.

OBJECTIVE: Defining how pregnant women respond to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vaccination is critical to optimize vaccination strategies that protect mother and infant at the epidemic. This study aimed to compare anti-SARS-CoV-2-spike immunoglobulin G (IgG) of vaccinated versus infected women and to determine the optimal timing of maternal vaccination during pregnancy at the time of epidemic. STUDY DESIGN: We collected maternal/cord blood at delivery (October 2021-March 2022) and measured anti-SARS-CoV-2-spike IgG geometric mean concentrations (IgG-GMCs) using a quantitative immunoassay. We compared groups according to timing and number of doses and correlated maternal and fetal IgG levels. We described the proportion of women with IgG levels above the 150 AU/mL positivity threshold according to the timing of infection/vaccination and performed a subanalysis for maternal IgG-GMC levels pre- and during the Omicron wave. RESULTS: We included 238 vaccinated women, 125 who received two doses and 113 three doses, and 48 unvaccinated infected women. All groups infected/vaccinated in the second or third trimester had an IgG-GMC above the positivity threshold. Third-trimester vaccination (second/third dose) resulted in higher maternal and cord-blood IgG-GMC compared to the second trimester (maternal-IgG: 102,32 vs. 4,325 AU/mL, p < 0.001; cord-IgG: 12,113 vs. 8,112 AU/mL, p < 0.001). Compared with infected-only women, a higher proportion of vaccinated women with ≥2 doses and their newborns had IgG levels above the positivity threshold at all time points. In vaccinated women, there were higher maternal IgG-GMC levels during the Omicron wave than pre-Omicron. CONCLUSION: At the time of epidemic, receiving an additional COVID-19 vaccine dose in the third trimester resulted in a higher IgG-GMC compared to the second trimester. Relatively higher levels of maternal and cord IgG-GMC were achieved following vaccination than infection. Women infected during or before the first trimester might benefit from an additional third-trimester dose to prevent peripartum infection and to passively immunize their newborn. The higher levels of maternal IgG-GMC in the Omicron period are suggestive of hybrid immunity. KEY POINTS: · Higher maternal anti-SARS-IgGs in vaccinated → infected.. · Higher cord anti-SARS-IgGs in vaccinated → infected.. · Third-trimester vaccine resulted in high-cord IgG levels..

Effect of Midurethral Sling Surgery on Vaginal Sensation.

INTRODUCTION: Previous studies have reported changes in the sensory functioning of the vagina in women with pelvic floor disorder. AIM: To evaluate vaginal and clitoral sensation before and after surgery with trans-obturator tape (TVT-O, Ethicon Johnson & Johnson). METHODS: Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina and clitoris 1 day before and 12 ± 4 months after surgery. MAIN OUTCOME MEASURES: Differences in thresholds to warm, cold, and vibratory sensations at a predetermined anatomic area of the genital region. RESULTS: Twenty-two women were admitted for midurethral sling surgery, and four were lost to follow-up. For the remaining 18 (mean age = 52 years, range = 37-65), we found a significant sensory decrease at the clitoral region to cold, warm, and vibratory stimuli after surgery. In contrast, in the anterior vaginal wall, there was a significant decrease only to warm stimuli after surgery. CONCLUSION: TVT-O can cause sensory loss in the clitoral and anterior vaginal wall region that can be measured and quantified. The effect of such sensory loss on sexual function and quality of sexual life needs further investigation.

Genital sensation in women with pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to compare vaginal and clitoral sensory thresholds in women with pelvic organ prolapse and women with normal pelvic anatomy. METHODS: Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina and clitoral area of women with pelvic organ prolapse, pelvic organ prolapse quantification (POP-Q) stage II or higher (study group) and of women without prolapse, POP-Q stage ≤ I (control group). The quantitative sensory tests were performed with a thermal and vibration Genito-Sensory Analyzer, at the distal third of the anterior and posterior vaginal wall and at the clitoral area. Warm stimuli were used to evaluate unmyelinated C-fibers; cold stimuli for thinly myelinated A-delta; and vibratory stimuli for large A-beta fibers. Independent Student's t test and Chi-squared test of association were used for analysis of continuous and categorical parameters respectively. RESULTS: Overall, 66 women, 22 with median POP-Q stage III (range: II-IV) and 44 with POP-Q stage I (range: 0-I), participated in the study. There were no statistically significant differences between the two groups regarding the characteristics examined (health status, medical history, and age). In all regions examined, mean thresholds for vibratory and warm stimuli were significantly higher and mean thresholds for cold stimuli significantly lower in the group with prolapse. CONCLUSION: Women with pelvic organ prolapse exhibited lower sensitivity in the genital area to vibratory and thermal stimuli than did women without prolapse. Our findings suggest that a neuropathic sensory deficit in the area of the genitalia might be associated with prolapse.

[Robotic-assisted surgery in urogynecology--our experience with the first 100 cases: experience from a single institution].

INTRODUCTION: The prevalence of surgery for pelvic organ prolapse repair is increasing. It is estimated that about 30% of women who underwent an operation for pelvic organ prolapse will need repeat surgery within a period of five years. The main reasons for surgical failure are attributed to difficulty in selecting the correct procedure for the type of prolapse and problems associated with the surgical technique. Sacrocolpopexy was originally described 55 years ago. However, expertise in laparoscopic sacrocolpopexy requires a relatively long learning curve. AIMS: To describe our experience in robotic sacrocolpopexy (RSC). METHODS: A retrospective study of the first 100 robotic sacrocolpopexy performed at a single medical center The primary outcomes examined were intraoperative bleeding, operative time, and hospitalization length. Secondary outcomes studied were surgical complications. Data were retrieved from patients electronic charts. RESULTS: The mean age and POPQ stage were 60 years 145-77 years) and median stage of III (II-IV), respectively. Estimated intraoperative blood loss was 41 ml (25-300 ml) and mean operative time was 177 minutes (range 114-299 minutes). The median length of hospital stay was 1 day (1-6 days). Adverse events were rare (4%) and not severe. CONCLUSIONS: Based on our experience with the first 100 cases, RSC is a feasible procedure with a low complication rate. RSC enables operating anatomically with a small amount of bleeding and a relatively short hospital stay following surgery. Long-term follow up is needed in order to evaluate the efficacy of RSC.

Steep Trendelenburg position during robotic sacrocolpopexy and heart rate variability.

OBJECTIVES: The objective of this study was to evaluate heart rate variability and hemodynamic parameters following steep Trendelenburg positioning during robotic sacrocolpopexy. STUDY DESIGN: For 19 women, median age 57 (range: 45-72), blood pressure and ECG were recorded during surgery. From the ECG signals interbeat intervals were used to assess heart rate variability, analyzed in time and frequency domains using the Fast Fourier transform. The low frequency and high frequency spectral bands were used to assess sympathetic and parasympathetic pathways respectively. RESULTS: All women underwent robotic supracervical hysterectomy and sacrocolpopexy. A statistically significant decrease in the mean values of the low-frequency and high-frequency spectral bands, representing sympathetic and parasympathetic activity, respectively were demonstrated 5min following Trendelenburg positioning of the patients (from 3.6±1.4 to 2.9±0.8ms(2)/Hz, and from 3.5±1.4 to 2.9±1ms(2)/Hz, P<0.05). These changes correlated with a mean 20% decrease in heart rate, which lasted for 30min, and with a second drop in sympathetic and parasympathetic activity and heart rate, commencing 2h from the start of surgery, and lasting until the end of the operation. CONCLUSIONS: Steep Tredelenburg positioning during robotic urogynecology surgery results in significant changes in the autonomic nervous system modulation of heart rate variability and in other hemodynamic parameters.

Combined spinal and general anesthesia vs general anesthesia for robotic sacrocervicopexy: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Gynecologic laparoscopic surgery is frequently accompanied by early postoperative pain. This study assessed the effect of combined general and spinal anesthesia on postoperative pain score, analgesic use, and patient satisfaction following robotic surgeries. METHODS: This was a randomized controlled trial. Thirty-eight consecutive women who underwent robotic surgeries for pelvic organ prolapse (sacrocolpopexy with or without subtotal hysterectomy) were randomly assigned to receive general anesthesia (control group, n = 20) or combined general with spinal anesthesia (study group, n = 18). Pain scores were assessed at rest and while coughing using a visual analog scale (VAS) 0-10. Dosage of analgesic medication consumption was retrieved from patients' charts. RESULTS: There were no statistically significant differences between the two groups with respect to demographic data and intraoperative hemodynamic parameters. In the postanesthesia care unit (PACU) mean total IV morphine and meperidine dosages were significantly lower for the study than the control group (0.33 vs 7.59 mg, 1.39 vs 27.89 mg, respectively, P < 0.003, <0.001, respectively). In addition, a significantly lower percentage of patients belonging to the study group demanded analgesic medications while in the PACU (33 vs 53 %, P = 0.042). Pain scores in the PACU and during postoperative day 1 were significantly lower in the study group than in the control group (delta VAS 1.9 vs 3.0, P = 0.04). Satisfaction with pain treatment among both patients and nurses was significantly higher in the study group. CONCLUSIONS: Reported levels of pain and analgesic use during the first 24 h following robotic gynecologic surgery were significantly lower following general and spinal anesthesia compared to general anesthesia alone.

Implementation of laparoscopic sacrocolpopexy: establishment of a learning curve and short-term outcomes.

PURPOSE: To evaluate the learning curve of senior urogynecologic surgeons performing laparoscopic sacral colpopexy (LSCP) and to assess outcomes and complications of LSCP. METHODS: We conducted a retrospective study of 47 consecutive women who underwent LSCP for pelvic organ prolapse repair between March 2009 and December 2010 at one tertiary medical center. Preoperative, intraoperative, postoperative, and demographic data were retrieved from patients' electronic charts. Pelvic organ support was assessed objectively using the Pelvic Organ Prolapse Quantification scale (POP-Q). Anatomic failure was determined as POP-Q stage ≥ II. RESULTS: The mean age of patients was 58 years (range 35-73 years). Seven (15 %) who opted to retain their uterus underwent sacrohysteropexies. The median POP-Q was III (II-IV). Of the 47 operations, 96 % (45) were completed by laparoscopy. The duration of surgery decreased as experience of the surgical team increased, from a mean of 196 ± 62 min for the first 15 cases to 162 ± 30 min for the subsequent 30. Four patients (9 %) presented with recurrence of prolapse; three (7 %) had de novo stress urinary incontinence; two sustained a cystotomy during adhesiolysis, and one had a port-site hernia. CONCLUSIONS: LSCP is a safe and effective treatment for pelvic organ prolapse, with very few complications. Following the first 15 cases of one surgical team, operative time decreased considerably.