Rate Of Vaginal Hysterectomy Research Articles

Vaginal hysterectomy at federal teaching hospital, Katsina: A five-year review.

Even though the vaginal route is said to be the gynaecologist route of surgery, abdominal hysterectomy remains the predominant method of uterine removal in most parts of the world, despite the evidence of the safety of vaginal hysterectomy. The study aims to determine the prevalence, socio-demographic variables, indications as well as outcome of vaginal hysterectomy at Federal Teaching Hospital (FTH) Katsina, during the 5-year study period. A five-year retrospective study on vaginal hysterectomy was conducted in Federal Teaching Hospital, Katsina from 1st January 2015 to 31st December 2019. The rate of hysterectomies (Abdominal & Vaginal) was 21.6% of the total major gynaecological surgeries performed during the study period. Vaginal hysterectomy accounted for 6.7%. The mean age and parity of the patients were 56.06+/- 9.55 years and 10.17+/- 4.57 respectively. The commonest indication was Utero-vaginal Prolapse (88.9%) and 80.5% (29) of the patients had no complications. Most of the patients (94.4%) were discharged within 7 days of surgery and there was no fatality. The rate of vaginal hysterectomy in our centre is low. Most of the patients were grand multiparous with the main indication being Uterovaginal prolapse. It is associated with favourable outcomes and very low complication rates.

Trends in Hysterectomy Rates Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic.

To compare nationwide trends in the rate of inpatient and outpatient hysterectomy between 2019 and 2020 during the coronavirus disease 2019 (COVID-19) pandemic. Using weighted data from the National Inpatient Sample and the National Ambulatory Surgery Sample, we examined the number of hysterectomies performed by month from 2019 through 2020. Monthly trends were compared between years overall, stratified by the route of surgery (abdominal, laparoscopic, and vaginal) and by indication for surgery (benign, preinvasive, cancer). Trends analyses were conducted using Joinpoint regression and reported as average monthly percentage change (AMPC). Differences in demographic characteristics between the years were compared using χ 2 tests. From January 2019 through December 2020, after weighting, 1,029,792 hysterectomies were performed, including 548,802 (53.2%) in 2019 and 480,990 (46.7%) in 2020. Starting in January 2020, monthly cases declined significantly, from 40,240 to a nadir of 10,566 hysterectomies in April 2020 (AMPC -29.2%, 95% CI -39.8% to -16.8%) ( P <.001). The subsequent months saw a significant increase in cases, from the nadir in April 2020 to 40,023 cases in July 2020 (AMPC 39.4%, 95% CI 18.6-63.9%) ( P =.001), which then stabilized to the end of the year (AMPC -1.3%, 95% CI -4.8% to 2.4%) ( P =.46). In March 2020 there was a 24.0% decrease, in April 2020 a 74.2% decrease, and in May 2020 a 35.1% decrease compared with the respective months in 2019. The rates of vaginal hysterectomy declined more than the rates of other routes of surgery, and procedures performed for benign and preinvasive disease decreased more than those for cancer. The rate of hysterectomy in the United States decreased in 2020 compared with 2019, with the greatest decrease from March to May of 2020, corresponding with the initial wave of COVID-19.

Vaginal Natural Orifice Transluminal Endoscopic Surgery Revolution: The Next Frontier in Gynecologic Minimally Invasive Surgery.

Despite guidelines that assert that the vaginal route for benign hysterectomy is preferred as the most minimally invasive approach, rates of vaginal hysterectomy remain very low in the United States. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) might reverse the trend. Potential advantages of vNOTES compared to traditional laparoscopic and robotic approaches include the potential for less pain, decreased operative time, improved cosmesis, and decreased risks. Importantly, vNOTES might allow for the conversion of laparoscopic and robotic routes back to vaginal due to surgeon factors.

7709 Tips and Tricks for Vaginal Hysterectomy

<h3>Study Objective</h3> The objective of this video is to review surgical techniques and tips for vaginal hysterectomy to improve provider confidence and serve as an educational tool. <h3>Design</h3> Audio narration, still images, and surgical footage will be used to review difficult scenarios and present an evidence-based approach to troubleshoot common issues. <h3>Setting</h3> Video footage was filmed with patients in dorsal lithotomy positioning in the operating room. <h3>Patients or Participants</h3> Patients with varying degrees of pelvic organ prolapse, ranging from stage 0-IV on POP-Q (Pelvic Organ Prolapse Quantification), were filmed during vaginal hysterectomy for heavy menstrual bleeding or prolapse repair. <h3>Interventions</h3> This video will review four common difficulties faced during vaginal hysterectomy: patient selection, the colpotomy, vaginal salpingectomy, and laparoscopically assisted vaginal hysterectomy. <h3>Measurements and Main Results</h3> This video discusses how to select candidates for vaginal hysterectomy including commonly misquoted contraindications. An approach, using the physical exam as guidance, is given for the anterior and posterior colpotomy and video footage is used to review how to troubleshoot the anterior entry. Steps to improve visualization for vaginal salpingectomy are discussed. Finally, laparoscopically assisted vaginal hysterectomy and how to divide the case between laparoscopic and vaginal approaches is reviewed to optimize success in the operating room. <h3>Conclusion</h3> This video reviews important steps of vaginal hysterectomy and provides tips to improve surgeon confidence. It can serve as an educational resource for trainees and early-career surgeons to improve their knowledge and confidence in performing vaginal hysterectomy. These types of resources are important to counter declining rates of vaginal hysterectomy and decreasing provider comfort in performing this operation.

Moving the Needle on Vaginal Hysterectomy: Implementing vNOTES at a Large Academic Medical Center

<h3>Study Objective</h3> To evaluate the adoption of vNOTES at a large resident driven county hospital and determine if this approach could significantly increase rates of vaginal hysterectomy. <h3>Design</h3> All hysterectomies done on the benign gynecology resident service of the presenter were included. A period of 24 months preceding the introduction of vNOTES (VANH: vaginal assisted vNOTES hysterectomy) was compared to a period of 24 months following the introduction of VANH. <h3>Setting</h3> Large County hospital resident gynecology service. <h3>Patients or Participants</h3> All patients presenting for hysterectomy for a 4-year period. <h3>Interventions</h3> The residents on each service block were introduced to vNOTES (VANH) as a route of hysterectomy. Residents suggest the desired route of surgery for each case, with faculty guidance as to relative and absolute contraindications for the planned route. In the early cohort, routes of hysterectomy were TVH, TLH, RA-TLH, and TAH. In the post intervention cohort, the routes of hysterectomy were TVH, VANH, TLH, RA-TLH, and TAH. <h3>Measurements and Main Results</h3> The main metric was the percentage of cases completed by each route, especially the percentage of cases completed vaginally, comparing TVH to TVH+VANH. An expansion in access to the daVinci Xi system resulted in an increase in the percentage of RA-TLH, so for the purposes of this analysis, these routes were considered together. Secondary considerations were conversion from planned route or complications. There were no conversions in the TVH or VANH category. Complications were correlated more with uterine size than planned route. <h3>Conclusion</h3> The addition of VANH to gynecological education can improve the access of residents to vaginal hysterectomies. By reducing perceived barriers to vaginal hysterectomy, it increases the number of patients considered candidates for vaginal surgery without increasing complications rates.

Tips and Tricks for Vaginal Hysterectomy

Vaginal hysterectomy is the preferred route of hysterectomy for benign gynaecological disease. Unfortunately, rates of vaginal hysterectomy are declining due to decreasing training opportunities and provider comfort. This video reviews important steps of vaginal hysterectomy and provides tips to improve surgeon confidence. It discusses how to select candidates for vaginal hysterectomy including commonly misquoted contraindications. An approach, using the physical exam as guidance, is given for the anterior and posterior colpotomy and video footage is used to review how to troubleshoot the anterior entry.

Formal institutional guidelines promotes the vaginal approach to hysterectomy in patients with benign disease and non-prolapsed uterus

ObjectivesThis study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital to determine if the use of formal guidelines and a standardised surgical technique would increase the rate of vaginal hysterectomy (VH) and result in an overall decline in open abdominal hysterectomy (AH). Study DesignAll women admitted between July 2001 and December 2014 for hysterectomy due to benign conditions, meeting the guidelines criteria (vaginally accessible uterus, uterus ≤ 12 weeks size or ≤ 280 g on ultrasound examination and pathology confined to the uterus) were included. The surgical route was determined using the Unit surgical decision tree algorithm. In cases where the pathology was not confined to the uterus or success in VH was uncertain, laparoscopic assisted vaginal hysterectomy (LAVH) was performed. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. In addition to the patient characteristics and surgical approach to hysterectomy, length of hospital stay, intra-operative and immediate post-operative complications were also recorded and analysed. ResultsA year before the initiation of the study, the percentage of all VHs undertaken in the Department was 9.8 % (mainly performed for utero-vaginal prolapse). During the study period, 1143 vaginal procedures (1017 VHs and 126 LAVHs) were performed. The most common indications were cervical dysplasia, uterine fibroids, dysmenorrhoea or abnormal uterine bleeding, adenomyosis, endometrial hyperplasia and chronic pelvic pain. Introducing a formal clinical decision tree algorithm and a standardised surgical technique resulted in an increase in the rate of VH to 48.4 % and overall decline in open AH from 91.2%–51.6%. Thus, the VH/AH ratio increased from 1/9 at the beginning of the study (July 2001) to 1/1 by its end (December 2014). In all cases, VH was performed without the need to convert the vaginal to the abdominal route. ConclusionThe use of institutional guidelines for determining the hysterectomy route and a standardised VH technique resulted in an increased number of performed VHs. This provided an essential opportunity for residents to acquire, improve and maintain the skills required to safely perform VH.

Retrospective Implementation of Algorithm for Route of Hysterectomy in Resident Clinic May Increase Rates of Vaginal Hysterectomy

Study Objective A resident-driven quality improvement project designed to evaluate whether retrospective application of a decision-making algorithm to guide selection of route for benign hysterectomy may have resulted in increased rates of total vaginal hysterectomy (TVH) in resident gynecology clinic. Design Retrospective chart review of all hysterectomies booked through resident pre-operative gynecology clinic over a five-year period. Setting Resident-run gynecology clinic in a large, urban academic medical center. Patients or Participants 162 patients underwent hysterectomy for benign indications in the five-year period under review (1/2015-12/2019). Interventions We created an algorithm to guide selection of route of hysterectomy for benign disease based on existing guidelines and review of literature. Electronic medical records (EMR) were reviewed for preoperative documentation of benign disease, uterine size and presence of adequate cervix, need for adnexal assessment (i.e. concern for large ovarian mass, endometriosis), concern for pelvic adhesions based on exam, or other rationale for route selection. The algorithm was retrospectively applied to identify which cases may have been preoperative candidates for TVH. Measurements and Main Results Retrospective application of our algorithm indicated that 61 of the 162 cases may have been candidates for TVH, and an additional 57 may have been candidates for an exam under anesthesia/diagnostic laparoscopy followed by possible TVH. Only 25 cases were booked as TVH; 5 were booked as EUA or diagnostic laparoscopy before TVH. Identified areas of improvement include assessment for adequate pelvis and proper counseling, particularly in “intermediate category” candidates. Conclusion By retrospectively implementing an algorithm to identify candidates for TVH, based on available documentation, it appears that a large percentage of cases booked from resident clinic could have been attempted vaginally. This shows opportunity for prospective implementation of the algorithm to increase rates of vaginal hysterectomy from the current rate of 15% to as high as 38%.

Difficult Vaginal Dissection of the Anterior Cul-de-sac: 5 Key Principles

Study Objective The rate of vaginal hysterectomy (VH) continues to decline likely due to the difficulty in performing the procedure, lack of adequate surgeon exposure and training and declining hysterectomy numbers. Dissecting the anterior cul-de-sac is a rate limiting step of the procedure due to incomplete dissection of vaginal attachments to the cervix, adhesions from previous surgeries, minimum uterus descensus and concern for bladder injuries. The objective of this video is to demonstrate 5 key surgical principles that can be used to facilitate the dissection of de anterior cul de sac. Videos from the laparoscopic approach will be brought in to emphasize these principles and techniques. Design N/A Setting N/A Patients or Participants N/A Interventions N/A Measurements and Main Results N/A Conclusion Dissection of the anterior cul-de-sac is a critical step in vaginal hysterectomy. We consider that this principles can help the surgeon to succeed: Completely excise the vaginal attachments from the cervix, incise the posterior leaf of the broad ligament, isolate uterine arteries bilaterally from posterior, dissect adhesions from lateral to midline and morcellate to decompress and achieve anterior descensus.

Trends in vaginal hysterectomy in a Nigerian teaching hospital: A 14-year review

Background: The procedure of vaginal hysterectomy is a fast disappearing art. This study looks at 14 years' experience of vaginal hysterectomy in Ile-Ife, Nigeria. Objectives: To determine and compare the rate, indications, and complications of vaginal hysterectomy over a 14-year period at Ile-Ife, Nigeria. Methods: The medical records of patients managed with vaginal hysterectomies performed from 1st January 2005 to 31st December 2018 were reviewed. The demographics and indications for vaginal hysterectomy were extracted. Data were analyzed using Statistical Package for Service Solutions – IBM version 22. Frequencies and percentages were calculated and associations compared where applicable using Chi-square with level of significance set at Results: Pelvic organ prolapse accounted for 0.8% of gynecological admissions and vaginal hysterectomy accounted for 2.3% of major gynaecological operations. The mean age was 66.1 ± 9.2 years with a mean age of menopause of 15.2 ± 7.1 years. The mean parity was 6.2 ± 1.6. Pelvic organ prolapse was the commonest indication. The mean blood loss at surgery was 314.2 ± 184.8 ml. The modal post-operative complication was post-operative anemia, and hypertension was the commonest comorbidity. The mean duration of surgery was 3 ± 0.9 h and the mean duration of admission was 5.4 ± 2.7 days. Conclusion: The rate of vaginal hysterectomy is on the decline. This may be due to case under reporting, limiting of family size, or low uptake of farming occupation in our society.

The Dying Art of Vaginal Hysterectomy: A Novel Simulation.

The rate of vaginal hysterectomy has decreased despite the procedure being the preferred hysterectomy method according to the American College of Obstetricians and Gynecologists (ACOG). Physicians have reported that some of the main barriers to performing minimally invasive hysterectomy are the size and shape of the uterus, difficulty of accessibility to the uterus, and surgeons' lack of training and experience. A simulation model for vaginal uterine morcellation was created in an effort to increase surgeons' confidence and to encourage them to select vaginal hysterectomy for their patients.The Conner model, where polyvinyl chloride (PVC) piping is used to simulate the pelvis and vaginal canal, was used as the basis for the pelvis. A medium-density fiberboard (MDF) was used as a base, while a PVC piping structure was used to stimulate the pelvis. The uterus was created from a peanut (car-wash) sponge that was carved into a triangle shape. The reusable MDF/PVC model was built in approximately one hour and cost under USD 30. The sponge uterus was built in approximately 10 minutes and cost under USD 2.Senior residents and faculty who have previously performed uterine morcellation participated in our simulation. Resident physicians reported that they felt more confident in their skills after the simulation. Both resident and staff physicians reported that the model had created a realistic experience.We created a novel model for vaginal uterine morcellation that was reported to be realistic in the initial investigation and increased confidence in the procedure for physicians. The model is easy to create, affordable, and partially reusable.

Teaching learners to raise the roof: a vaginal surgery simulator for apical suspension.

The objective was to discuss the importance of apical suspension following vaginal hysterectomy and demonstrate a surgical model to aide in educating learners on a variety of apical suspension procedures. Rates of pelvic organ prolapse are not insignificant following hysterectomy. Re-support of the vaginal apex should be performed at the time of hysterectomy in those with or without a diagnosis of prolapse. Exposure to vaginal apical support procedures may be limited owing to declining rates of vaginal hysterectomy and limited trainee work hours. Surgical models are increasingly being used to supplement operating room experience. The model we present was originally developed for hysterectomy, although its design allows for teaching a variety of apical support procedures that incorporate the uterosacral ligament (USL) for support. We demonstrate performing a USL suspension, internal McCall suture, and modified McCall suture using the model. The model is constructed from readily available supplies, is multi-use, and inexpensive. It allows learners to identify relevant anatomy, understand/visualize surgical steps, and practice suturing technique. Pelvic organ prolapse is common in women, although opportunities to teach apical suspension procedures may be limited. The proposed vaginal surgery simulator can be used to supplement the experience of gynecological surgery trainees with apical suspension procedures.

01: Basic technique of vaginal hysterectomy

Demonstrate the basic technique of vaginal hysterectomy. The American College of Obstetricians and Gynecologists has recommended the vaginal approach for hysterectomy whenever feasible. Despite better patient outcomes and cost benefits, the rate of vaginal hysterectomy is declining. One contributing factor is lack of training during residency. Our video outlines seven reproducible steps to perform a simple vaginal hysterectomy and can be used to improve resident training and promote learning outside of the operating room. This video can be used as an education tool for residents to learn the steps to successfully perform a simple vaginal hysterectomy.

An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members.

The Continuing Surgical Education Preceptor program (CSEP) was designed to meet population needs by facilitating development of new skills by practising surgeons. Elements include entry criteria, dedicated OR time, assigned preceptors, structured assessment of competence, a mechanism for credentialing, and a reimbursement model. This study analyzed the effectiveness of the CSEP in increasing the number of clinician educators performing laparoscopic hysterectomy (LH) without compromising rates of vaginal hysterectomy (VH) and in enhancing residents' training in performing minimally invasive hysterectomy (MIH; either LH or VH). We performed a retrospective descriptive study to longitudinally analyze the numbers and proportions of different surgical approaches to hysterectomy at two hospital sites over five years. The CSEP was implemented differently at the two sites. Success of the program was indicated by a surgeon performing 50% or more of hysterectomies as MIH. To assess the impact on resident education, we longitudinally analyzed the number of hysterectomy teaching cases performed as MIH. The proportion of surgeons performing 50% of hysterectomies as MIH steadily increased in the first five years after implementation of the CSEP. At one hospital, the proportion increased from 13% to 56%, due to an increase in LH cases with no change in VH cases. The proportion of resident LH teaching cases increased from 0% to 26%, with a similar rise in the proportion of MIH cases, although it did not quite reach the target proportion of 50% or more. Contrasting the experience of the CSEP between two hospitals revealed that having OR time dedicated to MIH cases provided significantly better results. The CSEP is an effective and sustainable model of lifelong learning applied to teaching practising surgeons new surgical skills.

Trend of hysterectomy: A retrospective analysis in Regional Institute of Medical Sciences (RIMS)

Background: Hysterectomy is the second most common operation done in women next only to cesarean delivery. Trend of hysterectomy has changed over times with development of newer ideas, techniques, etc. An attempt has been made to study it and to assess the current scenario. Aims: To review and analyze cases of hysterectomy with a view to suggest ways of improving health care. Materials and Methods: A retrospective study was conducted from January 2007 to August 2011 which included 1,285 cases of hysterectomy. Parameters like age, parity, indication, procedure were analyzed and data was presented in percentages and proportions. To avoid biased result, emergency and routine cases were analyzed separately. Result: Most women were of more than 45 years of age in planned cases and between 20 to 45 years in emergency cases. Uterine fibroid was the commonest indication (40.7%). Obstetrical complications were the main cause for emergency hysterectomies. The most common procedure was total abdominal hysterectomy but in emergencies, subtotal hysterectomy was the procedure of choice. The rate of vaginal hysterectomy was 10.7%. Ovaries were preserved in 12.7%. Conclusion: Hysterectomy is usually postponed till 45 yrs of age in planned cases. Uterine myoma is the most common pathology in planned procedure. In emergency, the indication varies. Abdominal route is still the preferred by most gynecologists. The rates of vaginal hysterectomy and preservation of ovaries are much lower than desired.

28 Years of Using Hysterectomy Guidelines to Determine the Feasibility of Vaginal Hysterectomy

Aim: To report on 28 years of using the guidelines for hysterectomy to determine the feasibility of vaginal hysterectomy. Methods: Patients with benign disease requiring hysterectomy were assigned type of hysterectomy by guidelines published in1995 according to uterine size, presumed extrauterine disease, and the accessibility of the vagina. Data for consecutive hysterectomies from 1980 to 2008 were collected and assembled into a database. Results: We identified 11,094 patients. The ratio of abdominal to vaginal hysterectomy was 1:92. The indications for hysterectomy were similar to the general population reported by the National Center for Health Statistics (NCHS). Uterine weights for 94.7% of patients were <280 g. Laparoscopy-assisted vaginal hysterectomy, as it was originally described and published in 1990, was used on 1264 patients to verify the presence of presumed severe extrauterine pathology. Vaginal inaccessibility that contraindicated the vaginal approach was present in 109 (1.0%) cases. Conclusion: When the guidelines were followed, the vaginal approach was found feasible in 98.9% (10975/11094) of patients with benign disease. This suggests that following guidelines will increase the currently declining rates of vaginal hysterectomy, which are of concern to the American College of Obstetricians and Gynecologists (ACOG).

Trends in Hysterectomy for Genital Prolapse: Rural Experience

The present study was conducted to investigate the trends of vaginal hysterectomy for genital prolapse in last 20 years by analyzing case records of affected women.During the analysis period, 4831 women underwent hysterectomy; records of 4223 (87.5%) were available. Of these, 911 (21.6%), 2.7% of 34,080 gynecological admissions, had vaginal hysterectomy for genital prolapse (study subjects).Eighty percent women who had vaginal hysterectomy for genital prolapse were over 40 years of age; however, most of these women had had the disorder for years before they presented. Only 4 (0.4%) women had not given birth, 874 (96%) women had had two or more births, and 383 (42%) had had 5 or more births. Having given birth was the major factor responsible for genital prolapse. In all, 94.2% of women presented with something coming out of the vagina.” Some women presented with abnormal vaginal bleeding or pain in abdomen as the chief complaint although they had had uterovaginal prolapse for years.There was no mortality and morbidity decreased over the years. There has been no change in the rate of vaginal hysterectomy for genital prolapse over the years. Surgical morbidity decreased trend, possibly because of the preoperative, intraoperative, and postoperative precautions taken, especially preoperative treatment of urinary and genital tract infection.Attempts need to be made to have safe births and a healthy life style so as to prevent genital prolapse and in case it occurs, therapy to prevent progression so that major interventions like hysterectomy are averted. Meticulous preoperative evaluation and planned therapy help in reducing surgical morbidity, if surgery becomes essential.

Vaginal Hysterectomy (Nonprolapsed) and Its Impact on a Patient with Gynecologic Menstrual Disorders: Experience in a Tertiary Care Hospital in Bangladesh

Abstract Introduction: Hysterectomy is a common gynecologic operation in woman all over the world. Alhough there are numerous benefits of vaginal over abdominal hysterectomy, all large-scale surveys of hysterectomy practice have shown that 70%–80% of all hysterectomies are performed abdominally. The rationale for this study is the statement that the vaginal route is to be preferred every time the anatomic conditions allow it and every time the nature of the lesions to be treated does not contraindicate it. Aims: The aims of this study were to evaluate the feasibility and complication rate of vaginal hysterectomy in women with enlarged uteri and other traditionally considered contraindications to abdominal surgery. Materials and Methods: Three hundred consecutive women with an enlarged uterus weighing between 280 and 2000 g and/or with the following commonly considered contraindications to vaginal surgery: previous pelvic surgery; history of severe pelvic inflammatory disease; moderate or severe endometrio...

Efficacy of using electrosurgical bipolar vessel sealing during vaginal hysterectomy in patients with different degrees of operative difficulty: A randomised controlled trial

Objective To assess the efficacy of electrosurgical bipolar vessel sealing using the LigaSure ® system during vaginal hysterectomy in comparison with conventional suture ligation method. Study design 103 patients undergoing vaginal hysterectomy for benign conditions were randomised to either LigaSure ® or Suture groups. Each group was divided into two subgroups according to the degree of surgical difficulty. Results Participants in the LigaSure ® had shorter procedure time (52.5 min vs. 90 min; p < 0.001) and less blood loss (230 ml vs. 360 ml; p < 0.001). Complication rates were not statistically different between the two groups. The advantage of the LigaSure ® system in reducing the operative blood loss was more pronounced in the more difficult procedures. Conclusion The LigaSure ® system reduces the operating time (by reducing pedicle-securing time) and blood loss without increasing the post-operative complication rates of vaginal hysterectomy. This beneficial effect was found to be more pronounced in difficult procedures.

Female urology: What method will you select?

When I was a resident, my leader taught me that the gold standard forpatients with stress incontinence is the Marshall–Marchetti–Krantz(MMK) procedure. But a few years later, urologists who could performadvanced techniques showed me needle suspension as the best methodat a urological meeting. Fortunately my boss gave me a chance for ahand-to-hand lesson of the stamay procedure by the specialist. Sincethen, I have been selecting this procedure for a few years. Withoutdoubt, this needle suspension was the gold standard at that time.But now most urologists do not select this technique because of badresults. After I had mastered the technique of tension-free vaginal tape(TVT), I could see the smiling faces of patients after the operation. Atthat time I believed that TVT would be the gold standard for thiscondition. But the present status is what you know.Recently most specialists, including myself, believe that using‘mesh’ is the best operation for patients with pelvic organ prolapse. Isthis tendency good for the patients in the long run? No one can predictthe results of this procedure more than ten years from now.God knows what procedure will be the gold standard in the future.Assistant Professor Yasuyuki Suzuki