Vaginal Access Research Articles

Isthmotsele: modern aspects of diagnosis, therapy and prevention of complications (Literature review)

Worldwide there is an increased rate of caesarean section (CS), which leads to an growth in the percentage of intra- and postoperative complications compared to natural childbirth. One of such longterm complications after abdominal delivery is a scar defect on the uterus after SC (isthmocele).This literature review provides up-to-date scientific information on the etiology, risk factors, diagnosis, modern methods of correction and prevention of complications of this pathology.Isthmocele, by definition, is a scar defect after SC or a niche of the uterine wall, which has the appearance of a myometrial tear or a triangular anechoic defect of the anterior uterine wall, which can be classified as a small or large defect depending on the thickness of the residual (remaining) myometrium. Pathognomonic clinical symptoms are abnormal uterine bleeding, chronic pelvic pain, and infertility.In addition, pregnancy in the scar after SC, placenta previa or placenta accreta spectrum (PAS), rupture of the uterus in the area of the postoperative scar can be complications of this pathology during gestation.The main risk factors for isthmocele, proven to date, are previous SC and retroflexion of the uterus, and the influence of the technique of suturing the uterus during SC requires further research.In order to diagnose isthmocele and determine the thickness of the residual myometrium, transvaginal ultrasound, infusion sonohysterography with physiological solution, and magnetic resonance imaging are used.Treatment of isthmocele can be medical or surgical, depending on the size of the niche, the thickness of the remaining myometrium, the presence of symptoms and the woman’s reproductive plans. In case of refusal or contraindications to medical treatment, surgical correction of the isthmocele should be offered. Surgical treatment includes minimally invasive approaches using hysteroscopy, laparoscopy, or transvaginal techniques.Hysteroresectoscopy involves partial removal of the myometrium along the edges of the niche with coagulation of vessels. Therefore, this technique if the residual thickness of the myometrium is <3 mm should not be used in women who want to get pregnant. In these cases, myometrial repair is of primary importance and can be achieved by laparoscopic, laparotomy, or vaginal access. The review also provides information on the most serious complication of isthmocele – the development of a pregnancy in a scar/niche and modern approaches to managing such pregnancy.

Opioid-free anaeshtesia in gynecology, future or a step back? –systematic review

Gynecological operations are surgical procedures involving the pelvic organs of a woman. They are divided into:laparoscopic, laparotomy and from vaginal access. The first two types are performed under general anesthesiawith opioids (Opioid Based Anasthesia, OBA). However, due to many side effects of opioids, non-opioid anesthesia(Opioid Free Anasthesia, OFA) has become more widely used. The following review focuses on the comparisonof postoperative pain, analgesic consumption, recovery quality, nausea and vomiting (PONV), hypotension andbradycardia between these two therapeutic approaches. The aim of this study is to perform comparative analysis ofthe effectiveness and side effects in gynecological surgeries using the OFA or OBA procedure. Review was performedwith MEDLINE, EMBASE, AMED databeses and the Cochrane Library, between September 2023 and December 2023.Randomised controlled trials (RCTs) comparing efficacy and side effects between OFA and OBA were included. Thereview comprised 498 patients from 6 RCTs. Common interventions included laparoscopic procedures. Evidence showsa reduction in side effects in OFA. PONV frequency was reduced in OFA (RR = 0.52; 95% CI: 0.29–0.93; p = 0.004;l2 = 67.5%). The score on the recovery quality questionnaire was also significantly higher (mean difference +28.36 points/200). The difference in pain, frequency of hypotension and bradycardia slightly favors OFA, but these changeswere not statistically significant. OFA procedure is not only an effective alternative to OBA in gynecological surgery, butalso improves the outcomes after it. Although, further research in this field is required.

The SAVVy study: SGS/AAGL survey of barriers for vaginal access surgery

The SAVVy study: SGS/AAGL survey of barriers for vaginal access surgery

Defining a Uterine Extraction Score based on a Volume/Access Ratio in Total Hysterectomy: a retrospective cohort study.

Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility. Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times. We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022. The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy. The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay. The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy. The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.

OUTCOMES OF FERTILITY-SPARING SURGERY IN WOMEN WITH EARLY- STAGE CERVICAL CANCER – CASE SERIES

Background: Globally, cervical cancer is the fourth most common and fourth leading cause of death among malignancies in women. In young women with early-stage cervical cancer (FIGO IA1-IB1) and low risk who wish to preserve their reproductive options, there are alternative surgical methods. They allow with minimal risk to treat the disease with a good prospect of getting pregnant and carrying the pregnancy. These methods include conization, simple trachelectomy, and radical trachelectomy, which can be performed via vaginal access, abdominal access, or minimally invasive (laparoscopic or robotic surgery). This case series examines the outcomes of fertility-sparing surgery in women with early-stage cervical cancer, focusing on the unique application of robotic-assisted techniques and their impact on preserving reproductive potential. Material and methods: This study includes five women aged 33-44 with early-stage cervical cancer who underwent fertility-sparing surgeries from March 2022 to March 2024. Surgical methods included simple trachelectomy and robot- assisted trachelectomy with pelvic lymph node dissection, performed at Saint Marina University Hospital - Pleven. Results: Key outcomes measured were operative time, hospital stay, intraoperative and postoperative complications, and reproductive success. There are no intraoperative complications. One early postoperative complication was registered - uncomplicated lymphocele. The operative time for robot-assisted tachelectomies is 105 and 120 minutes, respectively and a hospital stay of 4 days. The simple trachelectomies show an operative time between 30 and 45 minutes and a hospital stay of 2 days. No abnormal blood loss was noted. Тwo pregnancies were reported among patients - one conceived naturally and one by ART. Follow-up periods ranged from 3 to 24 months, with no cancer recurrences reported. Conclusion: Fertility-sparing surgeries demonstrate promising oncological and reproductive outcomes in selected patients with early-stage cervical cancer. These findings support the potential for broader application in clinical practice, emphasizing the importance of specialized surgical expertise.

Симптомокомплекс дивертикула уретры у женщин.

Introduction. Urethral diverticulum in women is one of the rarest urological diseases, its frequency ranges from 0.02 to 6%. Urethral diverticulum clinically manifests itself in patients between the third and fourth decades of life and its diagnosis is often difficult because urethral diverticulum can mimic other pelvic floor diseases. Often, incorrect diagnosis leads to the prescription of erroneous treatment for recurrent urinary infection, overactive bladder, urinary incontinence, chronic pelvic pain, etc. The aim of this article is to determine the correlation between the topographic-anatomical parameters of the diverticulum, clinical manifestations and results of surgical treatment. Methods and materials. For the purposes of the study, 50 patients with urethral diverticulum were included in the study. All patients were examined and operated on at the Department of Urology of A.I. Yevdokimov Moscow State University of Medicine and Density, on the basis of the S.I. Spasokukotsky State Clinical Hospital in the 3rd and 4th urological departments in the period 2019 to 2022. The duration of postoperative follow–up is 2 years. The results of the study were statistically processed. Results. Most often, patients with urethral diverticulum experience the classic triad of symptoms: dysuria, dispareunia, dribbling, as well as symptoms associated with an infectious-inflammatory process in the bladder and urethra. Analysis of symptoms showed that their presence and severity do not correlate with the size of the diverticulum. A statistically significant relationship was revealed between the size of the urethral diverticulum and the presence of postoperative complications. The larger the diverticulum, the higher the chance of complications in the postoperative period. The location of the urethral diverticulum does not affect the development of complications in the postoperative period. Conclusions. Based on the results of the study and analysis of the data obtained, the dependence of the frequency of complications (periodic increase in body temperature, weak stream during urination and stress form of urinary incontinence) after diverticulectomy via vaginal access on the size of the urethral diverticulum can be traced.

The effect of pelvic organ prolapse and various options for its correction on female sexual function: A review

The sexual activity of patients before and after the treatment of pelvic organ prolapse (POP) largely determines their quality of life and satisfaction with the intervention. This review analyzes current data on the nature of changes in sexual function in various pelvic organ prolapse correction methods. Particular attention is paid to a comparative assessment of the effect of available surgical techniques with abdominal and vaginal access on the risk of de novo dyspareunia. Based on the results of clinical studies and systematic reviews, the most optimal ways of correcting POP have been established; tools for assessing their effectiveness in routine clinical practice have been proposed; the importance of an interdisciplinary approach to the treatment of POP with the involvement of medical psychologists has been noted due to the significant role of emotional and behavioral factors in sexual dysfunction.

Reconsidering the best minimally invasive approach for patients with herlyn-werner-wunderlich syndrome: Should we push the frontiers for a better outcome?

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare congenital defect of the Mullerian ducts characterized by uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. It frequently presents during puberty, with complications such as pelvic pain, pelvic inflammatory disease and infertility. Surgical management is the mainstay treatment. A vaginal access for septum resection is usually used. However, it can be in difficult in several situations such as a very proximal septum with a small bulge, or in the case of virgin patients with social considerations regarding the hymenal ring integrity. Thus, a laparoscopic approach may be a beneficial alternative. In particular, laparoscopic hemi hysterectomy has recently gained remarkable interest due to its added benefit of treating the cause rather than treating only the symptoms. It removes the source of the bleeding, thus stopping the flow. However, it transforms a bicornuate uterus into a unicornuate uterus, leading to some obstetrical concerns. Should we push the frontiers further and consider laparoscopic hemi hysterectomy for better outcomes as the mainstay management of patients with OHVIRA syndrome?

Хирургия пролапса тазовых органов вагинальным доступом в специализированном центре: эволюция имплантов от «XL до XS»

Хирургия пролапса тазовых органов вагинальным доступом в специализированном центре: эволюция имплантов от «XL до XS»

The revival of vaginal surgery in the era of endoscopy: V-NOTES initial experience with a series of 32 patients.

Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) is an emerging surgical technique in the evolution of minimally invasive surgery. This technique allows different types of surgical procedures to be performed by vaginal access with endoscopic control. The combination of vaginal surgery and laparoscopy brings many advantages, especially the absence of incisions in the abdominal wall and better visualization of the abdominal cavity. In this retrospective study we report our initial experience of V-NOTES in benign gynaecologic surgery by describing our first consecutive 32 surgeries. From June 2020 to January 2022, 32 gynaecological procedures were performed by V-NOTES by the same surgeon in a university hospital. Perioperative outcomes were evaluated retrospectively. Conversion to laparoscopy or laparotomy and peri-operative and post-operative complications. None of the 32 V-NOTES procedures required conversion to conventional laparoscopy or laparotomy. We observed 2 intraoperative complications managed by V-NOTES and 2 post-operative complications (Clavien-Dindo Grade 2). Our results are similar to studies previously published about this subject and are promising concerning the techniques efficacy and safety. We do believe that a short training allows to reach benefits safely. However, further prospective multicentre randomized trials comparing V-NOTES to totally laparoscopic hysterectomy and to vaginal hysterectomy are needed to strengthen the validity of this new approach. V-NOTES widens the indications of vaginal hysterectomies by removing limitations such as large uterus, absence of prolapse, and history of caesarean. Moreover, this technique allows adnexal surgery to be performed by vaginal access.

Способ расширяющей кишечной пластики мочевого пузыря у больных с лучевыми пузырно-влагалищными свищами и микроцистисом.

Introduction. Radial vesicovaginal fistulas are one of the most difficult problems of urogynecology, despite the fact that modern technologies make it possible to personalize the use of radiation therapy. Standard surgical techniques in the treatment of such patients are ineffective. The search for alternative surgical solutions can improve the results of treatment of patients with radial fistulas and microcystis. Study objective. To compare the effectiveness of augmentation ileocystoplasty and two-stage surgical treatment, represented by expanding intestinal cystoplasty in combination with the use of a Martius or Martius-Symmonds flaps. Materials and methods. The study included 8 patients. The first group included 4 patients who underwent laparotomy, augmentation ileocystoplasty. In 3 patients relapsed fistulas were closed with vaginal access using a Martius flap a few months later. The second group included 4 patients who underwent expanding intestinal cystoplasty by laparotomy, with further formation of Martius or Martius-Symmonds flaps by perineal access and moving them into the pelvic cavity for fixation from the abdominal cavity. Results. The average duration of the operation in the first group was 337.5 minutes, in the second group – 470 minutes. The patients of the first group had no complications of the III-V groups according to Clavien-Dindo. Natural urination was eventually recovered in all patients. In 2 patients of the second group, postoperative complications were recorded: in 1 patient – complication of group IIIa according to Clavien-Dindo – marginal necrosis of the skin flap after abdominoplasty, which required stage necrectomy and secondary skin sutures, in another 1 patient – complication of group IIIb according to Clavien-Dindo – dynamic intestinal obstruction, which required relaparotomy and nasointestinal intubation. There were no relapses of vesicovaginal fistulas. After urination was restored, all patients retained the urge to urinate. Conclusion. The proposed two-stage operation allows not only to eliminate the vesicovaginal fistulas, but also to increase the capacity of the bladder, restore voluntary urination.

8144 Laparoscopic Robot-Assisted Hysterectomy with Vaginal Specimen Extraction Using Excite Technique of a Large Uterus

<h3>Study Objective</h3> Demonstrate a safe and didactic step-by-step hysterectomy of a leiomyoma large uterus using robotic platform and its vaginal specimen removal using Extracorporeal C-Incision Tissue Extraction (ExCITE) technique. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient was placed in semi gynecological position, arms alongside the body and legs 80 grades abducted in adjustable leggings. Three 8mm robotic portals were placed on umbilical scar and both flanks. One additional 5mm portal was set in the right flank, for laparoscopic assistance. <h3>Patients or Participants</h3> 48-year-old woman reports abdominal bulge and pelvic pain for 6 months, with progressive worsening, radiating to lumbar region and legs. She also reports increased menstrual flow, with important loss of quality of life. MRI of the pelvis showed uterus with estimated volume of 920 cm³, heterogeneous myometrium due to multiple fibroids, the largest with 9.0 × 6.6 × 6.5 cm (vol 200 cm³), vascularized, determining compression on the upper wall of the bladder. <h3>Interventions</h3> Robot-assisted laparoscopic total hysterectomy was indicated. In the abdominal inventory, an 8x enlarged uterus was observed with multiple intramural and subserosal myomas, as well as thin adhesions between mesorectal and posterior uterine wall. Procedure was performed safely with practically no blood loss at all, and uterus was removed by vaginal access, with cold-knife morcellation, using ExCITE technique. <h3>Measurements and Main Results</h3> We obtained a safe and efficient surgical treatment on a large uterus hysterectomy using robotic surgery, with specimen removal by cold-knife morcellation. Patient evolved with complete resolution of symptoms and satisfactory postoperative recovery. <h3>Conclusion</h3> We showed with our case report a safe and reproducible step-by-step of a large uterus robotic hysterectomy, showing that robotic platform can be an important tool when dealing with challenging large uterus. Moreover, large specimen removal, which can also be tricky, can be easily and safely performed using ExCITE technique.

8402 Two-Port Total Laparoscopic Hysterectomy and Excision of Simple Endometriosis in a Transgender Male Patient.

<h3>Study Objective</h3> To provide an overview of a two-port total laparoscopic hysterectomy with bilateral salpingo-oophorectomy in a transgender male patient and to demonstrate the feasibility of excision of simple endometriosis by this approach. <h3>Design</h3> Surgical video. The American College of Obstetricians and Gynecologists recommends vaginal approach to hysterectomy, whenever feasible; however, in the transgender male patient, the vaginal approach to hysterectomy may pose technical challenges due to limited vaginal access: vaginal atrophy (when on testosterone therapy), lack of uterine descensus due to nulliparity that is common, and often times infrequent or no vaginal intercourse. Moreover, the frequent desire for salpingo-oophorectomy in this population can make the vaginal approach a challenging one. When patients have history of dysmenorrhea and/or pelvic pain, laparoscopy offers an adequate intrabdominal survey to diagnose and treat endometriosis, which is precluded with vaginal access alone. <h3>Setting</h3> Academic hospital with a referral-based practice for the transgender male patient who desire gender affirming surgery. <h3>Patients or Participants</h3> 35-year-old nulligravid trans male with gender dysphoria and history of severe dysmenorrhea prior to beginning testosterone therapy, who desires gender affirming surgery by hysterectomy and bilateral salpingo-oophorectomy. <h3>Interventions</h3> A 5 mm umbilical trocar is used for a 30-degree camera to maximize visualization. A 5 mm suprapubic trocar for the single operative instrument is placed above the level of the uterus fundus. Success of a two-port hysterectomy is achieved by having excellent uterine manipulation to generate appropriate counter traction on the uterus. The hysterectomy is completed in the standard fashion, and the excision of simple endometriosis is completed with a single instrument by using blunt and sharp dissection. The vaginal cuff is closed vaginally. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> A two-port laparoscopic approach avoids placement of ancillary trocars on the appropriate patient. This technique can be also used in the appropriate cis-gendered patients. Excision of simple endometriosis can be feasible with the two-port approach.

7976 Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) with a Retroverted Uterus: Should the Approach Change?

<h3>Study Objective</h3> To demonstrate techniques that improve visualization and operative field for the removal of fallopian tubes in patients with retroverted or enlarged uterus encountered during vaginal natural orifice transluminal endoscopic surgery (vNOTES). <h3>Design</h3> Video demonstration. <h3>Setting</h3> Tertiary care center. <h3>Patients or Participants</h3> A reproductive-age patient was seen in the office for surgical sterilization. She was deemed a good candidate for VNOTES as she had no prior abdominal surgery and a small uterus. However, upon entry into the abdomen, the uterus was found to be retroverted. <h3>Interventions</h3> Routinely, three instrument sleeves are utilized with the vaginal access point in order to use a laparoscopic camera, a grasping instrument, and an instrument that cauterizes and excises the fallopian tubes. For a retroverted uterus, strategic access point preparation and instrument positioning techniques can improve visualization, maximize the operative working diameter, and decrease instrument collision. The instrument sleeves are placed in an inverted triangle, with the grasping instrument in the ipsilateral side of the fallopian tube being excised and the 30-degree laparoscope in the contralateral sleeve. The excising instrument is placed in the most inferior, most medial sleeve, maximizing the operative field. A fourth instrument placed directly in the air-tight gel below the inferior sleeve can lift the uterus to improve visualization of the fallopian tubes. <h3>Measurements and Main Results</h3> Patient was discharged home on thesame day. Two weeks post-operatively, there were no recovery complications. <h3>Conclusion</h3> The vNOTES procedure provides patients a minimally invasive option for surgical sterilization with fast recovery and negligible scarring. Surgeons may still consider a patient with a retroverted uterus a candidate for vNOTES by optimizing sleeve placement, instrument positioning, and utilizing a a fourth instrument to lift the uterus and better visualize the operative field. This technique may also be useful to improve visualization of fallopian tubes in the setting of a bulky or enlarged uterus.

Analysis of the informativeness of perioperative visual diagnostics of uterine fibroids

The aim. To analyze the methods of visual diagnosis used in reproductive age women with uterine fibroids.&#x0D; Materials and Methods. Retrospective analisys, information–analytical methods were used in the work. Sources of information were data from the scientific literature on the topic of the study, modern gadleins, a review of randomized controlled trials.&#x0D; Results. Depending on the types of visual diagnostics used in the preoperative examination were formed groups: I group (n=120) – patients were examined only by the sonographic method; II group (n=80) – patients were examined by MRI and ultrasound. Comparative analysis of the MRI and sonographic studies results determined the number of myomatous nodes inpatients of the II group (n=80 (100%): by ultrasound – solitary nodes in 52 (65%), multiple in 28 (35%), and by MRI – a solitary nodule in 37 women (according to FIGO classification – type SM0 – 16 women, SMI in 8 patients, SMII in 8 patients, O3–6 typein 5 women), two nodules in 27 people and three myomatous nodules in 16 women (among multiple myomas n=43 (100%) according to the FIGO classification, , were diagnosed: SM0/О3–4 type– 20 (47%), SM1/О3–4 type –13 (30%), SM2/ O3–4 type –10 (23%), and according to MP type: MP1 – 16 (37%), MP2 –11 (26%), MP3 –16 (37%), and among solitary nodes n=37 (100% ): MP1 – 27 (71%), MP2 –10 (29%). The frequency of cases of inconsistency the clinical situation with ultrasound data interms of the number and localization of myomatous nodes in multinodular UF, especially in SM0–2/О3–4 type combinations, was 39, 0%, and when was using MRI – 8.0% (p&lt;0.05). The structure of organ–preserving surgical intervention in the scope of myomectomy is presented as follows: hysteroscopy – 118 (59%), a combination of laparoscopy and hysteroscopy – 50 (25%), in 28 (14%) a combination of laparoscopy and hysteroscopy was converted to laparoscopic–vaginal access and 2.0% were converted to laparoscopic laparotomy. In the 1st group (n=120(100%)) where only preoperative ultrasound was used, a higher specific weight of conversions from hysteroscopy to laparoscopy – 36 cases (30%), from a combination of laparoscopy and hysteroscopy to laparoscopic–vaginalaccess – 24 (20%) and from laparoscopy laparotomy – 12 (10%).&#x0D; Conclusions. Ultrasound in the perioperative period is unable to fully determine clear navigation for the operation, especially for multinodular UF and hard–to–reach UF localization for hysteroscopic myomectomy. This clinical problem can be solved by using MRI in the perioperative diagnostic and intraoperative sonography.

Analysis of Different Routes of Hysterectomy Based on a Prospective Algorithm and Their Complications in a Tertiary Care Institute.

Introduction Hysterectomy is the most common gynaecological operation worldwide. The objective of the study is to analyze the various routes of hysterectomy and its complications when the decision of route is based on using a prospective algorithm tree. Methodology. It is an observational study to analyze the route of hysterectomy based on using a prospective algorithm. The decision tree is based on pelvic pathology, uterine size, vaginal access, pelvic adhesion, competency of the surgeon, choice of the patient, and complication of different routes of hysterectomy. Data were collected from preoperative, intraoperative, and postoperative records. Demographic factors, indications, routes of hysterectomy, and complications were recorded and analyzed by using SPSS software version 22. Observation. Among the malignant or suspected malignant pathology groups, TAH was performed in 89 cases and TLH was performed in 3 cases. Among the benign disease groups, VH was performed in 137(38.2%) cases, TAH was performed in 118(32.9%) cases, and TLH was performed in 104 (28.9%) cases. Operative time and a number of blood transfusions were significantly less with VH (p value < 0.0001 and 0.004) compared to abdominal and total laparoscopic hysterectomy. Postoperative complication such as fever was more with abdominal hysterectomy (<i>p-</i>value<0.00001) compared to VH and TLH. Vaginal discharge was more with VH and TLH compared to TAH (p value −0.004) and wound infection was more in the abdominal route (p value 0.001). Conclusion The abdominal route was the route of choice for surgery in malignancy or suspected malignant pathology. In benign pathology, VH was the most common and preferable route of surgery. Complications were found to be minimal with vaginal hysterectomy.

Personal experience of Non Descent Vaginal Hysterectomy (NDVH) in a District Hospital - A Study of 60 cases.

Objective(S): To share our experience and explore the safety &amp; feasibility of NDVH in 60 cases. Methods: This prospective observational study was conducted from Jan 2016 to Dec 2017 in Obstetrics and Gynaecology Department of Sylhet shaheed Shamsuddin Ahmed Hospital, Sylhet. Sixty patients requiring hysterectomy for benign nonprolapsed gynaecological disorders were the target population. Prerequisite for non-descend vaginal hysterectomy were uterine size not exceeding 20 weeks, adequate vaginal access with uterine mobility. Main outcome measures were i) Procedures of removal of large uterus ii) Time taken to complete the operation iii) Blood loss during operation iv) Postoperative hospital stay. v) Postoperative complications. Results: Vaginal hysterectomy was completed successfully in 100% cases. All patients were multiparous and in 41-45 years age group (37%). Commonest indication was AUB (37%), Second indication was fibroid uterus (35%) and next indication was adenomyosis (13%). In most of the case uterus was 10-12 weeks size (37%), in 28% cases uterine size was less than 8 weeks, 14-16 weeks size in 27% cases and uterus was more than 16 weeks size in 8% cases. Morcellation techniques like bisection, myomectomy, wedge resection and debulking were done to remove bigger sized uterus. Mean operating time was 45 minutes. Mean blood loss was 60ml. Average hospital stay was 3 day. Complications were minimum which included UTI and febrile morbidity. At 12 weeks postoperative follow up 72% patient had no adverse complain though 18% cases was drop out. Conclusions: Vaginal hysterectomy is safe feasible, scarless and patient friendly approach for benign gynaecological disorders other than prolapsed uterus. In this era of minimally invasive surgery, non-descend vaginal hysterectomy is to be considered as a safe option.

Пузырно-влагалищные свищи: современные концепции диагностики и лечения.

Introduction. Vesicovaginal fistula (VVF) is a pathological communication between the urinary bladder and the vagina. The lack of common approaches to the treatment choice, its timing and postoperative management of patients makes this disorder one of the challenges of modern urogynecology. Materials and methods. Relevant publications were searched using the PubMed database, the Google Scholar search system, and the scientific electronic library eLibrary.ru. Results. VVF is the most common form of urogenital fistulas. In developed countries, the formation of VVF mainly are the result of surgical trauma or radiation therapy, but in developing ones the majority of VVF have an obstetric etiology. There are different classifications of VVF; however, there is no overall accepted one that is suitable for predicting treatment efficacy and long-term outcomes regardless of etiology of VVF. Treatment of VVF with long-term bladder drainage should be performed only for small, benign and unformed VVF. Surgical closure of VVF is the primary method of treatment. Surgery can be performed using abdominal and vaginal access. Regardless of the access, a positive result (closure of the fistula) on average is achieved in 90,8% of cases. The treatment of post-radiation fistulas is more challenged and associated with a high failure rate. Conclusion. Despite of the variety of VVF treatment options, unfortunately, there is no the perfect one yet due to the variability of VVF ethiology, the lack of unified curative approaches and the shortage of studies comparing different therapies.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) hysterectomy in Singapore

Dear Editor, Hysterectomy is one of the most common gynaecological procedures, and various approaches are available such as abdominal, laparoscopic and vaginal.1 Several studies demonstrated that vaginal hysterectomy is preferable to laparotomy for superior surgical safety, less postoperative pain, and shorter hospital stay.2,3 However, its use is limited by large uteruses or narrow vaginal access,

Historical perspective of vaginal hysterectomy: the resilience of art and evidence-based medicine in the age of technology.

The aim of this study was to describe, from a historical perspective, the relevance, resilience and outcomes of vaginal hysterectomy (VH) in gynecology in the age of technological scenario. The authors searched records from January 2011 to January 2021 on the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library) for combinations of the terms "vaginal hysterectomy," "outcomes" AND "history"; and before that period, if the search had historical relevance. randomized clinical trials; hysterectomy performed for benign gynecological conditions; and VH outcomes compared with Abdominal Hysterectomy (AH), Laparoscopic Hysterectomy (LH) or Robotic Hysterectomy (RH). The VH combines sequences of reproducible techniques which have been developed over the years to safely and effectively overcome the limitations of difficult cases of vaginal extirpation from the uterus. The authors support endoscopic surgical approaches in complex surgery for benign indications, urogynecology, and gynecologic oncology when appropriate. However, what makes the gynecological surgeon different from the general surgeon is the vaginal access. It is essential to continue to train residents in vaginal surgical skills and provide safe and cost-effective patient care. The art of technology is the resilience of keeping only the patient at the center of innovation.