Canadian Task Force Research Articles

Laparoscopic blockage of uterine artery in the management of large cornual pregnancy

To present a technique of temporary uterine artery clamping before laparoscopic surgery for prevention of blood loss in cornual ectopic pregnancy. Step-by-step explanation of the entire surgical procedure using video and still images (Canadian Task Force classification III). Tertiary university-based hospital. A 37-year-old woman who presented with amenorrhea of 55 days and extremely high β-hCG level of 281,400 mIU/mL. Transvaginal ultrasound examination revealed a 7 cm mass with ample blood supply invading the muscularis layer around the right uterine cornua. Institutional Review Board and Ethics Committee approval was obtained. After pelvic adhesiolysis, retroperitoneum was dissected and the bilateral uterine arteries were exposed. To reduce the possibility of massive hemorrhage, titanium clips were used to temporarily block the bilateral uterine arteries. Laparoscopic inspection showed the mass as dark and blue, consistent with the diagnosis of cornual pregnancy. After removal of the cornual lesion, 2-0 Vicryl was used to reconstruct the uterine cornua. At the end of the surgery, the titanium clips were removed to reverse the uterine blood supply. The surgery lasted for about 2 hours, with estimated blood loss of only 50 mL. The patient recovered completely and was discharged 2 days postoperatively, without any further bleeding or postoperative complications. The pathological examination confirmed the diagnosis of cornual pregnancy. One month later, the β-hCG levels decreased to within normal range. At 6-month postoperative follow-up, ultrasound examination showed a normal size uterus. Temporary blockage of the uterine artery during surgery could prevent heavy blood loss, especially in difficult surgeries such as myomectomy for complex uterus fibromas or adenomyomectomy. Moreover, this technique would be feasible for emergent cases, including conservative surgery for cesarean scar pregnancy, and could also replace traditional uterine artery embolization for treating cornual pregnancy.

Quality assessment of global lung cancer screening guidelines and consensus

Objective: To understand the research progress and quality of lung cancer screening guidelines and consensus in China and abroad, and to provide reference for the formulation of high-quality lung cancer screening guidelines in China. Methods: Databases including PubMed, Medline, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, SinoMed, VIP and Wanfang Data were searched, websites and important references were also searched by hand retrieval. The Appraisal of Guidelines for Research & Evaluation Ⅱ(AGREE Ⅱ) and Reporting Items for Practice Guidelines in Healthcare (RIGHT) were used to assess the quality of newly published or updated guidelines and consensus. Results: A total of 9 guidelines and consensus published between 2015 and 2020 were included in this study, with countries including the United States, China, Canada, Saudi Arabia and South Africa. The field of scope and purpose and clarity of presentation scored relatively high but the rigor of development and applicability scored low. Five guidelines were judged to be A-level, all of which were published abroad, and the remaining four were B-level, including three guidelines and consensus issued by China and 1 guideline issued by South Africa. The report rate of RIGHT were higher in basic information and background, lower in review and quality assurance, funding and declaration and management of interests. There were 5 guidelines with a good level and 4 guidelines and consensus with a moderate level. The best overall quality guidelines were those published by the American College of Chest Physicians in 2018 and by the Canadian Task Force on Preventive Health Care in 2016. Conclusions: The number of countries and institutions that issue lung cancer screening guidelines and consensus had been increasing gradually, but the quality in China remained low. It is necessary to develop high-quality lung cancer screening guidelines suitable for China's national conditions in combination with evidence-based methods to guide practice.

Screening for depression in children and adolescents: a protocol for a systematic review update

BackgroundMajor depressive disorder is common, debilitating, and affects feelings, thoughts, mood, and behaviors. Childhood and adolescence are critical periods for the development of depression and adolescence is marked by an increased incidence of mental health disorders. This protocol outlines the planned scope and methods for a systematic review update that will evaluate the benefits and harms of screening for depression in children and adolescents.MethodsThis review will update a previously published systematic review by Roseman and colleagues. Eligible studies are randomized controlled trials (RCTs) assessing formal screening in primary care to identify children or adolescents not already self-reporting symptoms of, diagnosed with, or treated for depression. If no or only a single RCT is available, we will consider controlled studies without random assignment. Studies of participants with characteristics associated with an elevated risk of depression will be analyzed separately. Outcomes of interest are symptoms of depression, classification of major depressive disorder based on a validated diagnostic interview, suicidality, health-related quality of life, social function, impact on lifestyle behavior (e.g., substance use, school performance, lost time at work, or school), false-positive results, overdiagnosis, overtreatment, labeling, and other harms such as those arising from treatment. We will search MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, and grey literature sources. Two reviewers will independently screen the titles and abstracts using the liberal accelerated method. Full-text screening will be performed independently by two reviewers using pre-specified eligibility criteria. Data extraction and risk of bias assessments will be performed independently by two reviewers. Pre-planned analyses, including subgroup and sensitivity analyses, are detailed within this protocol. Two independent reviewers will assess and finalize through consensus the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and prepare GRADE evidence profiles and summary of findings tables for each outcome of interest.DiscussionThe systematic review will provide a current state of the evidence of benefits and harms of depression screening in children and adolescents. These findings will be used by the Canadian Task Force on Preventive Health Care to inform the development of recommendations on depression screening.Systematic review registrationPROSPERO CRD42020150373

Screening for the prevention and early detection of cervical cancer: protocol for systematic reviews to inform Canadian recommendations

PurposeTo inform recommendations by the Canadian Task Force on Preventive Health Care on screening in primary care for the prevention and early detection of cervical cancer by systematically reviewing evidence of (a) effectiveness; (b) test accuracy; (c) individuals’ values and preferences; and (d) strategies aimed at improving screening rates.MethodsDe novo reviews will be conducted to evaluate effectiveness and to assess values and preferences. For test accuracy and strategies to improve screening rates, we will integrate studies from existing systematic reviews with search updates to the present. Two Cochrane reviews will provide evidence of adverse pregnancy outcomes from the conservative management of cervical intraepithelial neoplasia. We will search Medline, Embase, and Cochrane Central (except for individuals’ values and preferences, where Medline, Scopus, and EconLit will be searched) via peer-reviewed search strategies and the reference lists of included studies and reviews. We will search ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Two reviewers will screen potentially eligible studies and agree on those to include. Data will be extracted by one reviewer with verification by another. Two reviewers will independently assess risk of bias and reach consensus. Where possible and suitable, we will pool studies via meta-analysis. We will compare accuracy data per outcome and per comparison using the Rutter and Gatsonis hierarchical summary receiver operating characteristic model and report relative sensitivities and specificities. Findings on values and preferences will be synthesized using a narrative synthesis approach and thematic analysis, depending on study designs. Two reviewers will appraise the certainty of evidence for all outcomes using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and come to consensus.DiscussionThe publication of guidance on screening in primary care for the prevention and early detection of cervical cancer by the Task Force in 2013 focused on cytology. Since 2013, new studies using human papillomavirus tests for cervical screening have been published that will improve our understanding of screening in primary care settings. This review will inform updated recommendations based on currently available studies and address key evidence gaps noted in our previous review.

An Audit of Opportunistic Lung Cancer Screening in a Canadian Province.

Objectives:Lung cancer is a leading cause of cancer-related death in Canada. Early detection can improve outcomes and despite recommendations from the Canadian Task Force on Preventive Health Care to screen patients who are 55 to 74 years old and have a 30+ pack-year history, formal screening programs are rare in Canada. Our goal was to determine if screening is being performed in a representative Canadian population, if recommendations are being followed, and how screening impacts lung cancer stage at diagnosis and prognosis.Methods:A retrospective chart review was performed to identify patients either screened for lung cancer or imaged due to lung cancer symptoms in Eastern Newfoundland between 2015 and 2018. Age, smoking history, screening modality, diagnosis, cancer stage, and mortality were recorded.Results:Under 6.0% of the eligible population were screened for lung cancer with only 28.13% meeting age and smoking criteria and being screened appropriately with low-dose CT. However, 70% of patients that had lung cancers found by screening met age and smoking screening criteria. While lung cancer detection rates were similar, screening detected cancer in patients at an earlier stage (50% Stage 1) compared to patients who were not screened (20% Stage 1). Patients who were screened had an improved prognosis.Conclusions:Physicians are opportunistically screening for lung cancer, but not consistently following screening guidelines. As screening is sensitive, leads to earlier stage diagnosis, and has a mortality benefit, implementation of an organized screening program could increase quality assurance and prevent many lung-cancer related deaths.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery.

To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery. All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications. The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars. Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery. We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A). Surgeons performing laparoscopic gynaecological surgery. RECOMMENDATIONS.

Robot-assisted Transvaginal Single-site Sacrocolpopexy for Pelvic Organ Prolapse

To demonstrate stepwise techniques for the successful use of the laparoscopic single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Academic tertiary care hospital. The patient, aged 69 years gravida 2 para 2-0-0-2 with a history of SVD × 2, presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap -1). The preoperative vaginal length was measured at 9 cm. Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, the retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomic variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer, and effective. Several helpful techniques in robot-assisted transvaginal single-site include the following: (1)The use of a 30°-angled scope alternating between "facing up" and "facing down" depending on the need for dissection or suturing. (2) The use of 3-dimensional visualization with a robotic camera that can highlight the depth of the surgical anatomy, therefore facilitating easier identification in the dissection of a surgical pedicle. (3) The use of wristed instruments that permit increased articulation and triangulation that are lacking in traditional laparoscopic single-site surgery, allowing for much easier and proficient suturing and knot tying. (4) Integration of the robotic platform that stabilizes the fine motor movement in a surgeon's hands improving the precision of the suturing and knot tying. The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. Robot-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse. Patients experience improved cosmesis, decreased postoperative pain, and faster recovery compared with abdominal sacrocolpopexy.

The times they are a-changin': The evolution of prostate cancer screening practices and beliefs among primary care physicians in Victoria, British Columbia.

Prostate cancer screening practices remain controversial among primary care practitioners (PCPs). Inconsistent guidelines and publication of large prostate cancer screening trials have failed to provide definitive guidance. This study investigates the evolution of prostate cancer screening practices and beliefs over 12 years, in Victoria, British Columbia. Questionnaires were delivered to 119 randomly selected PCPs in 2019. Descriptive analysis together with exploratory graphs and Pearson Chi-squared test for independence was calculated. The 2008 data was compared by determining if their value fell within the 2019 data's 95% confidence interval. Response rate was 69.8% (83/119); 30.1% of PCPs reported regularly screening asymptomatic men with prostate-specific antigen (PSA) testing and 37.3% reported regularly performing digital rectal exam (DRE). The combination of PSA and DRE was the most used (48.2 %) screening modality. Most (73.5%) reported that guidelines influence their screening practices, with the most popular choice being those published by The Canadian Task Force on Preventive Health Care (CTF) (32.5%). The results demonstrate a movement away from prostate cancer screening among PCPs when compared to 2008. PCPs believe that DRE and PSA are less valuable as screening tools and that there is insufficient evidence to support their use. The most used initial screening modality was the combination of PSA/DRE, however, we found a decrease in their use between the two study periods. Clinical guidelines continue to influence PCPs screening practices, but the shift of more PCPs following the CTF guidelines since 2008 has likely led to the reciprocal decrease in prostate cancer screening.

Cervical Screening Practices and Outcomes for Young Women in Response to Changed Guidelines in Calgary, Canada, 2007-2016.

The aim of the study was to describe temporal trends in screening and outcomes for women, after changes in guidelines in Alberta, Canada, that raised starting age to 21 years, then to 25 years of age, and reduced frequency to 3 yearly. Calgary Laboratory Information System data were used to examine screening rates, follow-up procedures, and cancer among women 10-29 years from 2007 to 2016 in the whole population of Calgary. Interrupted time-series analyses were used to assess changes in screening and subsequent diagnostic procedures over the 10-year period. Annual screening rates dropped by approximately 10% at all ages older than 15 years after the 2009 Alberta cervical cancer screening guidelines, followed by a steady decrease. Further change continued subsequent to minimal apparent effect of the 2013 Canadian Task Force on Preventive Health Care guidelines. The rates of abnormal test results decreased in concert with decreased screening. No increases in cervical intraepithelial neoplasia 1, cervical intraepithelial neoplasia 2/3, or invasive cervical cancer rates were observed after reduced testing. The largest decrease in screening and follow-up procedures occurred in the period immediately after implementation of 2009 Alberta screening guidelines. The number of consequent procedures also decreased in proportion to decreased screening, but there was no increase in cancer rates. Starting screening at the age of 25 years and reducing intervals seem to be safe.

Guideline No. 401: Sonographic Cervical Length in Singleton Pregnancies: Techniques and Clinical Applications.

• To assess the association between sonography-derived cervical length measurement and preterm birth. • To describe the various techniques to measure cervical length using sonography. • To review the natural history of the short cervix. • To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. Women at increased risk of a short cervix or at risk of preterm birth. Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care (Online Appendix Table A1). Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SUMMARY STATEMENTS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES): RECOMMENDATIONS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES).

Techniques for Apical Prolapse Management in Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension

To demonstrate practical tips and tricks for successful use of the transvaginal natural orifice transluminal endoscopic surgery (NOTES) technique for performing high uterosacral ligament suspension (HUS). Stepwise demonstration with narrated video footage (Canadian Task Force classification III). An academic tertiary care hospital. A 58-year-old G2P2, NSVDx2 with stage III anterior vaginal prolapse, stage II uterine prolapse, and posterior vaginal prolapse. The preoperative vaginal length was 7-cm. Transvaginal NOTES is a creative yet difficult approach that averts an abdominal incision while simultaneously providing enhanced visualization in comparison with traditional vaginal surgery [1]. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and bilateral salpingo-oophorectomy was subsequently performed. The following key techniques were used to perform NOTES-HUS: tagging the sutures for bilateral uterosacral ligament before single-site port placement, identifying the ischial spine and ureters, pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament, grasping and lifting the uterosacral ligament while placing a suture, and giving the suture a tug after placement to confirm the correct location [2-4]. The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 5-cm. Postoperative pelvic organ prolapse quantification was stage 0. Transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. There is an increased cost to using laparoscopically assisted NOTES surgery as well as a risk of pneumoperitoneum. Applying the tips and tricks presented here, such as tagging the uterosacral ligament before port placement and so on, the challenging transvaginal NOTES-HUS technique can be performed efficiently and safely.

Benign Gynaecological procedures by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES): Complication data from a series of 1000 patients

To evaluate the safety and feasibility of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological indications. Prospective observational study (Canadian Task Force classification II-3) in a non-university teaching hospital. One thousand consecutive patients (2013-2018) who were eligible for vNOTES approach to benign gynaecological surgery were included. Patient data and perioperative outcomes were included for analysis after the vNOTES surgical approach was standardized and made the default route of surgery. Of the 1000 vNOTES cases performed during this study period, hysterectomy (73%) was the most common followed by adnexal surgery (18%) and salpingectomy (4%). The mean age of the patient cohort was 46 yrs of age (22-83) and mean BMI, 26 kg/m2(16.5-52). There was a conversion rate of 0.4% (4 cases), 3 to conventional laparoscopy and 1 to laparotomy. The mean operating time was 42 minutes (14-250 minutes). The total complication rate was 3.9% (39) of which 1% (10) was intraoperative complications and 2.9% (29) were post-operative complications. When the hysterectomy cohort was sub analyzed, the total complication rate was 5.2% in this group (intraoperative 1.4% and post-operative 3.8%) with only a 0.4% complication rate in the non-hysterectomy sub-group. Of the complications in the hysterectomy group there were 9 cystotomies (1.2%). The mean specimen weight for all hysterectomies was 172 g (20-3361 g) with an average operating time of 46 minutes (20-250). The perioperative outcomes of this large vNOTES case series for benign gynaecological indications is comparable to other vNOTES procedures reported in the literature apart from the risk of cystotomy which is a hysterectomy specific risk. The outcomes are that of a single high-volume surgeon incorporating cases within his respective learning curve of the surgical technique and as such should be interpreted accordingly. Since 2015 the International NOTES Society has initiated a prospective complication database where all vNOTES surgeons are invited to register their cases.

Stepwise Laparoendoscopic Single-site Pectopexy for Pelvic Organ Prolapse

To demonstrate stepwise techniques for the successful use of the laparoendoscopic single-site surgery (LESS) technique for safely performing pectopexy. Stepwise demonstration with narrated video footage (Canadian Task Force classification III). An academic tertiary care hospital. Patient was a 48-year-old, gravida 2 para 2, having had 2 normal spontaneous vaginal deliveries, with stage III anterior vaginal prolapse and stage III uterine prolapse and posterior vaginal prolapse. The preoperative vaginal length was 6 cm. Laparoscopic sacrocolpopexy is the current gold standard for pelvic organ prolapse demonstrating a low recurrence rate; however, it can be technically challenging to perform, particularly in women with obesity or in the event of an anatomic variation. The pectineal ligament, also known as Cooper's ligament, is familiar to surgeons and can be used for a tension-free mesh suspension in patients with prolapse. Integration of LESS and pectopexy is a novel alternative, minimally invasive approach that is more cosmetic, simpler, and effective. The key steps in LESS pectopexy include the following: MEASUREMENTS AND MAIN RESULTS: The procedure was performed successfully in approximately 80 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. LESS is a feasible technique for pectopexy in patients with pelvic organ prolapse. A LESS pectopexy results in better cosmesis and offers an alternative for patients with challenging pelvic organ prolapse, such as those with obesity.

Mass Spectrometry in Prediction of the Myomas Recurrence

Study Objective The mass spectrometric study of changes in the lipid profile of various tissues in patients with recurrent fibroids and the use of mass spectrometric data in the prediction of myoma recurrence. Design Level II-1, Canadian Task Force. Setting National Medical Research Center, Moscow, Russia. Patients or Participants Lipid analysis of the myometrium, fibroids, and plasma was conducted in 66 patients: 35 patients with newly diagnosed uterine fibroids (UF) and 31 patients with recurrent myoma (RUF). Plasma only was studied in the control group of 15 patients who underwent intrauterine septum resection. A semi-quantitative assessment of tissue lipid levels was performed using direct mass spectrometry. A semi-quantitative assessment of blood plasma lipidome was conducted. The suitability of biomarkers for diagnostics was assessed. Interventions Laparoscopic myomectomy, followed by lipid analysis of obtained samples of myometrium, fibroids, and plasma. Measurements and Main Results Significant differences were found in the levels of lipids involved in the metabolism of glycerophospholipids, sphingolipids, triglycerides, fatty acids when studying uterine fibroids. Studying of the myometrium identified the difference in the levels of lipids involved in the metabolism of glycerophospholipids, lipids with an ether bond, and sphingolipids. In patients with recurrent disease, linoleic acid metabolism was altered in the tissues of the fibroids and not in the myometrium. Significant differences were found in the levels of cholesterol esters, triacylglycerols, (lyso) phosphatidylcholines, and sphingomyelins when comparing the plasma of the control group with the plasma of the UF and RUF groups. When comparing plasma of groups UF and RUF, lipids belonging to the classes of cholesterol esters, phosphotidylcholines, sphingomyelins, triacylglycerols were identified as significant. Conclusion A broad, diagnostically significant panel of potential serologic biomarkers for the diagnosis of recurrent myoma was identified in this study.

Three Original Methods of Laparoscopic Colpopoiesis from the Pelvic Peritoneum. Tactics Selection and Results of Treatment

Study Objective To compare results of 3 original techniques of laparoscopically assisted colpopoiesis from pelvic peritoneum. Design Level II-1, Canadian Taskforce. Setting Department of Operative Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Healthcare of Russia Patients or Participants We recruited 203 patients with utero-vaginal aplasia, gonadal dysgenesis, testicular feminization, congenital adrenogenital disorders, male-to-female transgenders. Interventions Adamyan's technique of laparoscopically assisted colpopoiesis from pelvic peritoneum has been used for more than 30 years. Since 2012, we have used three original methods of laparoscopic neovagina creation from pelvic peritoneum: laparoscopic-perineal technique, total laparoscopic technique and combined laparoscopic-perineal technique with ligatures used for bringing down the peritoneum. Measurements and Main Results Total of 71 patients underwent colpopoesis using a laparoscopic-perineal technique: in 94 cases - total laparoscopic technique of colpopoiesis and in 38 - laparoscopic-perineal technique with ligatures were used. 27 patients had history of unsuccessful attempts for surgical neovagina creation. There were no significant differences between three types of colpopoesis in blood loss, duration of surgery, length of postoperative hospital stay and in use of pain relievers postoperatively. From the standpoint of complications, 1 case of bladder injury, 1 case of rectal injury in patients with previous fibrosis were diagnosed and eliminated during surgery followed by asymptomatic recovery. Postoperative neovaginal stricture was seen in 5 cases and dyspareunia was seen in 11 cases, which improved with vaginal maintenance dilation within 1 month. Conclusion Laparoscopy Involving neovagina creation is an effective and safe operation even in patients with unsuccessful previous neovagina attempts and radiation induced fibrosis.which provides sufficient length of neovagina of 10-12 сm, functional aspects such as lubrication, epithelialization, extensibility and sensibility. However, such interventions especially in complex cases should be provided in the specialized medical centers.

Single-Port Laparoscopy Versus Conventional Laparoscopy of Benign Adnexal Masses during Pregnancy: A Retrospective Case-Control Study

Study Objective This study aimed to compare the operative outcomes of single-port laparoscopy (SPL) with those of conventional laparoscopy (CL) of adnexal masses during pregnancy. Design Retrospective case-control study (Canadian Task Force classification II-2). Setting Tertiary care academic medical center. Patients or Participants The study included all patients who underwent laparoscopic surgery for adnexal masses during pregnancy from October 2010 to January 2020. Interventions Among them, 22 patients underwent SPL surgeries and 42 patients underwent CL surgeries.For perioperative outcome evaluation, relative data were collected. The patients were followed up by telephone for cosmetic results, pregnancy and neonatal outcomes. Measurements and Main Results No differences in maternal age, parity, multiple gestation, high-risk pregnancy, and history of cesarean section were found between the two groups. Overall cosmetic satisfaction with the scar was significantly favorable in the SPL group compared with the CL group (9.1±1.7 vs 8.1±1.3, p=0.002). While SPL surgeries took significantly longer time than CL surgeries (69.2±21.0 min vs 54.7±20.7 min, p=0.02). Operative blood loss (p=0.948), decrease in estimated hemoglobin level (p=0.779), average length of hospital stay (p=0.657), and hospitalization expenses (p=0.245) were not remarkably different between the two groups. Pregnancy outcomes, neonatal Apgar scores at 1 and 5 min, and average birth weight were also comparable. No incisional hernia was detected in both groups. Conclusion SPL provides better cosmetic satisfaction than CL, but does not cause additional perioperative danger, economic burden, adverse pregnancy, and adverse neonatal outcomes in adnexal surgery during pregnancy. Therefore, for better cosmetic outcomes, SPL could be considered as a feasible and safe surgical option for adnexal masses in pregnant women.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension (NOTES-HUS) for Apical Prolapse

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal NOTES technique for preforming HUS. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Patients or Participants A 58-year-old G2P2, NSVDx2 with Stage III anterior vaginal prolapse, Stage II uterine prolapse & posterior vaginal prolapse. The preoperative vaginal length was 7 cm. Interventions High uterosacral ligament suspension (HUS) is well accepted for apical prolapse due to its advantages of good apical support and simplification of intraperitoneal suture passage. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel minimally invasive approach that avoids an abdominal incision while providing improved visualization, leading to simplified intraperitoneal suture placement. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and BSO was subsequently performed. The following key techniques were utilized to perform NOTES-HUS: ○ Tagging the sutures for bilateral uterosacral ligament before single-site port placement ○ Identifying the ischial spine and ureters ○ Pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament ○ Grasping and lifting uterosacral ligament while placing a suture ○ Giving the suture a tug after placement to confirm the correct location Measurements and Main Results The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion The transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. Applying the tips and tricks presented here, such as tagging uterosacral ligament before port placement, etc., the challenging transvaginal NOTES-HUS can be performed efficiently and safely.

Prediction of Need for Morcellation during Total Laparoscopic Hysterectomy

Study Objective With all the concerns surrounding uterine morcellation, our objective was to identify predictors of the need for morcellation during total laparoscopic hysterectomy (TLH). Design A retrospective cohort study (Canadian Task Force classification II-2). Setting University Hospital Center. Patients or Participants Women undergoing a TLH for a benign gynecologic pathology form January 1st 2017 to January 31th 2019. Interventions All women underwent a TLH. If the uterus was to voluminous to be removed vaginally, surgeons favored in-bag morcellation by laparoscopy. Uterine weight (uterine length x maximum width x anteroposterior diameter x 0.52) and characteristics (number and volume of leiomyomas) were assessed prior to surgery by ultrasound or MRI in order to predict the need for morcellation. Measurements and Main Results A total of 252 women underwent a TLH during the two-year period. Women had a mean age of 46±7 (30–71) years old and the three main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572)±272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least one leiomyoma. Among women with a uterine weight 500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥ 250 versus Conclusion Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.

Technique and Initial Results of the Laparoscopic Nerve Sparing Ultralateral Resection (LaNSURe) of Parametrial Endometriosis

Study Objective Parametrial endometriosis (PE) is a poorly understood and under-recognized form of deeply infiltrating endometriosis and represents a suspected cause of persistent pelvic pain after traditional excision of endometriosis. The detailed description of the clinical symptoms and signs associated with this presentation of the disease, as well as the success rate of the outcomes of the radical LaNSURe treatment strategy will contribute to closing a substantial gap in endometriosis care in Canada. Design Retrospective-prospective cohort study of patients undergoing a surgical intervention (Canadian Task Force II-3). Setting Tertiary Referral Center. Patients or Participants Interim analysis of an ongoing retrospective-prospective study that currently includes 28 patients who underwent the LaNSURe technique for the treatment of pathology-confirmed PE. Interventions Radical laparoscopic treatment of endometriosis, including a unilateral or bilateral parametrectomy using the Laparoscopic Nerve-Sparing Ultralateral Resection of Endometriosis (LaNSURe) technique. Measurements and Main Results Before each preoperative visit, patients filled out a questionnaire which included Visual Analog Scale (VAS) to report the average pain they experience, the maximum pain during flare ups and the minimal pain they feel as well as specific health-related quality of life questionnaires. The primary outcome was the average VAS scores before surgery and at the last postoperative visit. Mean follow-up time was 4.3±2.1 months. The Average VAS post-surgery significantly decreased from preoperative 5.9±1.9 to 4.0±2.5 (p=0.004). Maximum pain went down from 7.9±2.2 to 5.3±3.0; (p=0.001). McGill Pain Questionnaire improved from 34.6±19.5 to 23.5±15.9 (p=0.04), Pain Catastrophizing Scale from 28.4±12.7 to 16.4±14.9 (p=0.005), and Pelvic Floor Distress Inventory from 164.7±44.3 to 136.2±40.6 (p=0.03). Twenty out of 28 (71.4%) patients underwent one or more previous excision surgery by an endometriosis specialist. Conclusion The LaNSURe technique is effective at improving overall pain and quality of life while preserving nerve function in the pelvic floor.

Combined Minimally Invasive Approach to Preserving Fertility in Patients with Cervical Pregnancy

Study Objective Assess the feasibility of the minimally invasive methods in preserving the fertility in patients with cervical pregnancy. Design Canadian Task Force: Level II-2 Prospective and retrospective analysis. Setting Department of Operative Gynecology, V.I Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation; Moscow, Russian Federation. Patients or Participants 66 women with cervical pregnancies desiring preservation of fertility (ages 25-44 years), treated at the Department of Operative Gynecology during the past 13 years. Interventions Standard diagnostic clinical protocol was carried out in all patients. Patients with cervical pregnancy received intravenous methotrexate at an average of 50 mg/every 48 hours and 6 mg of intramuscular leucovorin rescue injection at 28 hours after methotrexate administration followed by resectoscopy or combined selective uterine embolization and resectoscopic approach. 2 women with massive bleeding on admission required hysterectomy. Measurements and Main Results The gestational age on admission ranged from 5 to 11 weeks with mean gestational age being 6.8 ± 0.8 weeks. 64 women underwent combined therapy with preoperative systemic methotrexate and resectoscopic excision. 28 of these patients had chorionic invasion into the cervix and required selective uterine artery embolization (SUAE), followed by resectoscopy. 2 patients with massive bleeding underwent emergent hysterectomy. Uterus preserving surgical procedures were started when a decreasing levels of β-hCG of 4000-7000I U/l were demonstrated. Bilateral SUAE was utilized in 28 cases, through the right femoral approach (12 cases) and through the right radial artery (16). The blood loss in all cases was less than 25 cc, including the ones with chorionic invasion. Conclusion The results of our study suggest that resectoscopic removal of embryos with previous cytostatic therapy with methotrexate allows for the preservation of fertility in young women with early cervical pregnancy. SUAE provides minimal operative blood loss and shorter hospital stay, and preserves reproductive potential in women with chorionic cervical invasion.