BACKGROUND:Hysterectomy is one of most performed gynecological procedures worldwide. Recent decades have witnessed a significant uptake of laparoscopic approaches. While technical proficiency is increasingly recognized as being closely linked to patient outcomes in different surgical specialties, standardization of assessment in minimally invasive gynecological surgery remains challenging. This study aimed to develop and validate a comprehensive assessment tool for robotic-assisted and laparoscopic hysterectomy and investigate associations between surgical performance and perioperative outcomes. METHODS:An international multi-center mixed-method study was conducted. Literature review was performed, and statements were proposed by a steering group of seven expert gynecologists, followed by a Delphi consensus to identify essential procedural phases, potential technical errors or near misses. The resulting assessment tool was validated using 40 unedited minimally invasive hysterectomy videos assessed by multiple raters under a national prospective multi-center observational cohort study. Inter-rater and intra-rater reliability were calculated using Cronbach's alpha and intraclass correlation. Concurrent validity was assessed through correlation with a validated error assessment tool (OCHRA), while predictive validity was established by correlating scores with clinical outcomes including operative time, blood loss, and postoperative complications according to the Clavien-Dindo classification. RESULTS:Consensus was achieved amongst 17 international experts from 6 countries on the composition of an objective assessment tool, composed of seven phases and four quality measures. Inter-rater and intra-rater reliability and internal consistency were considered excellent: ICC = 0.969 (CI: 0.922-0.986, p < 0.001), ICC 0.810 (CI: 0.800-0.842, p = 0.002), and Cronbach's α per phase was 0.743-0.834. When controlling potential confounders a higher STELLAR score was associated with shorter operating time, less blood loss and fewer post operative complications. Increased tool score was associated with significant lower chance of post-operative complications: rs = -0.438, (CI: -0.173 to -0.657, p = 0.004). CONCLUSIONS:Operative performance during laparoscopic and robotic-assisted hysterectomy can be objectively measured and correlated with clinical outcomes. This newly developed objective assessment tool can be used for surgical quality assurance of surgical techniques during education and training sessions or surgical trials.

STUDY OBJECTIVE:To determine the characteristics of adolescent and young adult patients undergoing surgery for severe endometriosis METHODS: We analyzed the British Society for Gynaecological Endoscopy (BSGE) database, a multicenter database of research-consented patients undergoing excision of surgically confirmed deep endometriosis, from 2009 to 2021, which includes prospectively collected preoperative questionnaire data and intraoperative findings reported by the surgical team during laparoscopy. Patients were divided into adolescent (10-19 years), young adult (20-24 years), and older adult (≥25 years) groups. Preoperative questionnaires and intraoperative findings were compared between groups. RESULTS:The study included 14,670 patients from 104 specialist endometriosis centers, of whom 186 were adolescents and 892 were young adults. Young adults had worse premenstrual and menstrual pain, dyspareunia, dysuria, and bladder voiding difficulty than older adults, despite higher use of hormonal contraceptives (35.1% vs 17.7%, P < .001) and opioids (32.5% vs 27.8%, P = .004). Adolescent patients had lower prevalence of bowel (66.7% vs 81.1%, P < .001), ovarian (30.6% vs 51%, P < .001), deep sidewall (65.1% vs 78.1%, P < .001), and uterosacral ligament endometriosis (74.2% vs 85.0%, P < .001) compared with older adults. The same was true for young adults, who also had higher rates of superficial disease (79.7% vs 70.9%, P < .001) than older adults. Older adults had a higher number of pelvic sites affected by endometriosis than adolescents (6.0 vs 4.57, P < .001) and young adults (6.0 vs 4.9, P < .001). CONCLUSION:Adolescent and young adult patients undergoing endometriosis surgery report severe preoperative symptoms but have fewer anatomical sites affected and fewer deep endometriotic lesions than older adults. These findings highlight differences in lesion distribution that warrant further investigation into disease progression.

STUDY QUESTION:How does the frequency and location of endometriosis lesions observed at laparoscopy vary with patient age? SUMMARY ANSWER:We find that older patients have more deep lesions and ovarian endometriomas at laparoscopy, although this plateaus around 30 years of age. WHAT IS KNOWN ALREADY:The natural history and aetiology of endometriosis remain uncertain, with evidence of progression, spontaneous regression, and stable disease in various studies. STUDY DESIGN, SIZE, DURATION:Cross-sectional analysis of a prospectively collected surgical registry, including data from 104 accredited endometriosis centres across 7 countries, with 14 670 cases in total. PARTICIPANTS/MATERIALS, SETTING, METHODS:We analysed data from the British Society for Gynaecological Endoscopy (BSGE) endometriosis centres database, a multicentre international prospective cohort of patients undergoing surgery for deep endometriosis. We included all patients aged 10-55 years from 2009 to 2021. The change in lesion prevalence with age was modelled using three different logistic regression models-non-quadratic, quadratic, and segmented, adjusted for whether they had undergone endometriosis excision in the past. MAIN RESULTS AND THE ROLE OF CHANCE:We identified 14 670 cases from 104 centres across 7 countries. The mean age at the time of surgery was 35.9 years (SD 7.4). The odds of superficial endometriosis decreased linearly with age by 3% per year (adjusted odds ratio (aOR) 0.97, 95% CI 0.96-0.97, P < 0.001). The following increased before plateauing: bowel endometriosis increased by 7% per year (aOR 1.07, 95% CI 1.05-1.09, P < 0.001) until 32.9 years of age (95% CI 30.5-35.3); deep sidewall disease increased by 7% per year (aOR 1.07, 95% CI 1.05-1.09, P < 0.001) until 31.3 years (95% CI 29.2-33.5); and uterosacral disease increased by 4% per year (aOR 1.04, 95% CI 1.02-1.06, P < 0.001) until 33 years (95% CI 29.3-36.6). Deep bladder disease increased by 12% per year (aOR 1.12, 95% CI 1.04-1.22, P = 0.005) until 28.2 (95% CI 25.8-30.6) years, after which the odds decreased by 2% per year (aOR 0.98, 95% CI 0.97-1.00, P = 0.007). Ovarian endometrioma was best described by a quadratic model, with a starting increase in odds of endometrioma of 20% per year at 10 years (aOR 1.20, 95% CI 1.16-1.23, P < 0.001), and a peak prevalence at 40.9 years of age (95% CI 34.1-47.7, P < 0.001). The total number of sites affected by endometriosis increased by 0.12 sites per year (95% CI 0.10-0.14, P < 0.001) until 32.8 years of age, with no correlation with age after this point. LIMITATIONS, REASONS FOR CAUTION:This cross-sectional study only includes patients undergoing excision with pararectal dissection for the treatment of pain, so does not capture patients who do not undergo such surgery, including asymptomatic patients, and cannot provide data on potential disease progression on an individual level. WIDER IMPLICATIONS OF THE FINDINGS:This study supports existing evidence suggesting that older patients with endometriosis have more deep nodules and endometriomas and less superficial disease. STUDY FUNDING/COMPETING INTEREST(S):No funding was provided for this study. K.V. reports consulting fees from Eli Lilly, Gedeon Richter, Gesynta, and Rickett (all paid to institution); speakers' fees from Gedeon Richter and Reckitt (both paid to institution); membership of the Medical Advisory Panel of Endometriosis UK (unpaid); past presidency of the International Association for the Study of Pain (IASP) Special Interest Group (SIG) on Abdominal and Pelvic Pain (unpaid). TRIAL REGISTRATION NUMBER:N/A.

Background:Rectovaginal/colorectal endometriosis is severe form of endometriosis requiring complex surgery, where pre-operative gonadotrophin releasing hormone agonists (GnRHa) are used to improve the surgical outcomes but the evidence supporting this is limited. Objectives:To evaluate the association between pre-operative use of GnRHa and perioperative and postoperative complications in patients undergoing surgery for rectovaginal or colorectal endometriosis. Methods:We analysed prospectively collected data from British Society for Gynaecological Endoscopy-accredited endometriosis centres between 2009 and 2021. Multivariable logistic regression analysis was performed to model the odds of each complication by pre-operative GnRHa use, controlling for patient age, body mass index, smoking status, whether a hysterectomy was performed, history of previous endometriosis surgery and surgical complexity. Main Outcome Measures:The association of GnRHa use with perioperative and postoperative complications. Results:We included 9,433 patients aged 18-55 years from 101 specialist endometriosis centres from six countries including UK, USA, Sri Lanka, Saudi Arabia, Turkey and Iran. Patients receiving pre-operative GnRHa were associated with higher rate of perioperative complications [odds ratio (OR): 1.31, 95% confidence interval (CI): 1.08-1.59, P=0.007], late complications (OR: 1.477, 95% CI: 1.15-1.9, P=0.002) and pelvic haematoma (OR: 2.251, 95% CI: 1.41-3.64, P<0.001). After controlling for confounding factors, GnRHa use remained significantly associated with colostomy (aOR: 4.05: 95% CI: 1.51-12.7, P=<0.001] pelvic haematoma (aOR: 3.08, 95% CI: 1.72-5.75, P<0.001) and abscess (aOR: 2.25, 95% CI: 1.10-4.79, P=0.029). Health related quality of life (HR-QOL) improved in the Pre-GnRHa group at 12 months and 24 months (mean difference 2.09/100, 95% CI, 0.27-3.92, P=0.025) and (mean difference 2.85/100, 95% CI 0.55-5.16, P=0.015). Conclusions:Pre-operative use of GnRHa has been associated with a higher incidence of perioperative and late complications, including significantly increased odds of colostomy, pelvic hematoma and abcess formation. There is need of careful patient counselling and further prospective research to clarify the pre-operative use of GnRHa in rectovaginal/colorectal endometriosis. What is New?:There is need of caution use of pre-operative GnRHa in deep rectovaginal/colorectal endometriosis surgery due to increased association of the risks of complications such as colostomy, pelvic haematoma and abcess. Despite long-term improvement in HR-QOL, there is need for careful patient selection and counselling.

Background:The efficacy of medical and surgical treatment of endometriosis-associated pain is a source of ongoing controversy. There is a lack of evidence about gonadotropin-releasing hormone agonists (GnRHa) use on long-term pain control, bladder and bowel symptoms for patients having surgery for deep rectovaginal/colorectal endometriosis. Objectives:To assess the effect of preoperative GnRHa (pre-GnRHa) use on pain, bowel and bladder symptoms for patients undergoing surgery for deep rectovaginal/colorectal endometriosis. Methods:The study evaluated data from the British Society for Gynaecological Endoscopy database, a large international multicentre prospective cohort of patients who underwent deep rectovaginal/colorectal endometriosis surgery between 2009-2021. We included 9433 patients from 101 accredited endometriosis centres. Multivariable logistic regression analysis was used to evaluate the association between pre-GnRHa use and postoperative pain, bowel and bladder symptoms at different time points, controlling for confounders like patient age, body mass index, smoking status, and hysterectomy. Main Outcome Measures:Rate of cyclical and non-cyclical pelvic and menstrual pain, bowel and bladder symptoms. Results:The mean age of the patients was 36 years (18-55). Pre-GnRHa use was associated with significant postoperative improvement in premenstrual pain [odds ratio (OR): 0.30, 95% confidence interval (CI): -0.57 - -0.034, P=0.02*], menstrual pain (OR: 0.41/10, 95% CI: -0.7 - -0.13, P=<0.001*), non-cyclical pain (OR: 0.27/10, 95% CI: -0.5 - -0.04, P=0.021*) and lower backache (OR: 0.30, 95% CI: -0.532 - -0.087, P=0.006*) up to 12 months postoperatively. Moreover, bladder pain was significantly reduced in the pre-GnRHa group at 12 months (OR: 0.24, 95% CI: -0.451 - -0.039, P=0.01*). Significant improvements were observed in bowel symptoms including frequent bowel movements (OR: 0.10, 95% CI: -0.194 - -0.012, P=0.02*), incomplete emptying sensation (OR: 0.10, 95% CI: -0.196 - -0.023, P=0.01*), cyclical dyschezia (OR: 0.43, 95% CI: -0.724 - -0.142, P=0.003*) and non-cyclical dyschezia (OR: 0.28, 95% CI: -0.504 - -0.075, P=0.008*) up to 12 months. Conclusions:Pre-GnRHa use is associated with a significant reduction in postoperative menstrual pain and non-menstrual pain as well as improved bowel and bladder symptoms lasting up to two years. It is also valuable to improve the quality of life for patients undergoing surgery for deep rectovaginal/colorectal endometriosis. What is New?:This is the largest prospective international study evaluating pre-GnRHa use in deep rectovaginal/colorectal endometriosis surgery. It provides evidence supporting the role of pre-GnRHa as an adjuvant to surgical treatment, to reduce postoperative pain and improve bowel and bladder function.

This literature review summarises the investigation into using Indocyanine Green (ICG) in the surgical management of endometriosis, focusing mainly on its application in Deep Endometriosis (DE). The study reviews the development, fluorescence characteristics, and clinical usage of ICG in enhancing the precision of identifying endometrial lesions during surgery. Emphasizing the technology's contribution to improved lesion visualisation, the paper discusses how ICG facilitates increased diagnostic accuracy, potentially reducing recurrence rates and the necessity for subsequent interventions. Additionally, it explores ICG's role in minimizing the risk of iatrogenic injuries, especially in ureteral endometriosis, and its utility in surgical decision-making for rectosigmoid endometriosis by evaluating bowel perfusion. Conclusively, while acknowledging the clear benefits of ICG integration in endometriosis surgical procedures, the abstract calls for more extensive research to validate its efficacy and cost-efficiency in the broader context of endometriosis treatment.

Background: Several endometriosis classification systems have been proposed and published but the search for a universal language that communicates the complexity, laterality and severity of this disease continues. The authors introduce the Visual-Numeric Endometriosis Scoring System. VNESS is a novel system for describing surgical findings in each compartment of the pelvis in a way that is simple to use, visually intuitive and mirrors a laparoscopic image of the pelvis. Objective: The aim of this study was to assess inter-rater reliability for components of VNESS. Materials and Methods: The project took the format of a validation study using short surgical laparoscopic video clips. Anonymised video clips of endometriosis procedures were scored by 50 Gynaecologists of varying levels of experience from 12 different countries. The clips were collated from a series of procedures performed between 2012 and 2022. Each participant scored 93 short surgical clips using VNESS. 4650 scores were compared against a reference score and analysis was performed to assess inter-rater reliability. Main outcome measures: The outcome measures were percentage agreement between given and reference scores, as well as intra-class correlation coefficients (ICC), Cohen Kappa and Quadratic Weighted Kappa Coefficients calculated to evaluate inter-rater reliability. Results: The highest and lowest percentage agreement with the reference score was seen in VNESS 4 (full thickness disease, 97% perfect agreement) and VNESS 1 (superficial disease, 53% perfect agreement) respectively. The intraclass correlation coefficient showed strong inter-rater reliability for all VNESS compartments except the vagina. Conclusions: This study suggests that VNESS has excellent reliability between observers. Correlation is stronger with more severe disease.

Background:Our study aimed to create a novel technique using n-butyl cyanoacrylate (n-BCA) for minimal access simulation training on cadavers in deep endometriosis excision. Objectives:A step-by-step video demonstration of using n-BCA in cadavers to simulate deep endometriosis. This technique is integrated into training sessions using cadavers aimed at enhancing surgical proficiency for deep endometriosis procedures. Material and Methods:Video article describing using n-BCA in cadavers as a simulation model. Result:This technique has been used in a hands-on cadaveric training course, and positive feedback supports the recommendation to incorporate this technique. Conclusion:Utilizing a human cadaver model proves beneficial for enhancing understanding of deep pelvic innervation. Implementing n-BCA in these cadaver dissections demonstrates both reproducibility and safety. This approach significantly contributes to refining surgical expertise in the excision of deep infiltrating endometriosis.

Objective: To compare the effectiveness of endometriosis excision alone to excision plus hysterectomy, with and without bilateral oophorectomy, for endometriosis-related symptoms. Design: Multicentre prospective cohort. Setting: Eighty-six specialist endometriosis centres. Population: Women undergoing rectovaginal endometriosis surgery between 2009 and 2021. Methods: We performed multivariable regression with random effects for patient and centre, controlling for age, BMI, smoking, laparoscopic versus open approach and type of bowel surgery performed, with sensitivity analysis for loss to follow-up. Main Outcome Measures: Pain scores, bowel symptoms and quality-of-life measures. Results: Compared to endometriosis excision alone, women undergoing hysterectomy with conservation of ovaries had greater improvement in non-cyclical pain (MD: 1.41/10, 95% CI: 1.03-1.78, p < 0.001), dyspareunia (MD: 1.12/10, 95% CI: 0.71-1.53, p < 0.001), back pain (MD: 1.29/10, 95% CI: 0.92-1.67, p < 0.001) and quality-of-life scores (MD: 8.77/100, 95% CI: 5.79-11.75, p < 0.001) at 24 months post-operatively. Women undergoing hysterectomy with bilateral oophorectomy also had greater improvement in non-cyclical pelvic pain (MD: 2.22/10, 95% CI: 1.80-2.63, p < 0.001), dyspareunia (MD: 1.05/10, 95% CI: 0.59-1.52, p < 0.001), back pain (MD: 1.18/10, 95% CI: 0.77-1.59, p < 0.001) and quality of life (MD: 12.41/100, 95% CI: 9.07-15.74, p < 0.001) at 24 months compared to endometriosis excision alone. Compared to hysterectomy with ovarian conservation, hysterectomy with bilateral oophorectomy was associated with greater improvement in non-cyclical pelvic pain (MD: 0.81/10, 95% CI: 0.32-1.30, p = 0.001) at 24 months and quality of life (MD: 3.74/100, 95% CI: 0.56-6.92, p = 0.021) at 12 months, although this result was sensitive to loss to follow-up. Conclusions: Patients who undergo endometriosis excision plus hysterectomy experience greater improvement in pain and quality of life compared to those who have endometriosis excision alone. There are additional benefits of bilateral oophorectomy with hysterectomy, although its value is less clear due to loss of follow-up.

Background:There is no agreed consensus on the optimal surgical treatment for pain associated with endometriosis.Objectives:To compare improvement in symptoms and quality-of-life in patients undergoing excisional endometriosis surgery (EES) versus EES with hysterectomy and bilateral salpingo-oophorectomy (EES-HBSO).Methods:This study evaluated patients undergoing EES and EES-HBSO at a single endometriosis centre between 2009 and 2019. Data was obtained from the British Society for Gynaecological Endoscopy database. Adenomyosis was assessed by blinded re-analysis of imaging and/or histology data.Main outcome measures:Pain scores (numeric rating scale 0-10) and quality-of-life scores (EQ-VAS) before and after EES and EES-HBSO.Results:We included 120 patients undergoing EES and 100 patients undergoing EES-HBSO. After controlling for baseline characteristics and the presence of adenomyosis, there was greater post-op improvement in non-cyclical pelvic pain amongst patients undergoing EES-HBSO compared to EES alone.The baseline pain scores had improved in the EES-HBSO cohort by 2.106/10 at 6 months (95%CI 0.469-3.742, p=0.012), 2.642/10 at 12 months (95%CI 0.871-4.413, p=0.004), and 2.548/10 at 24 months (95%CI 0.681-4.414, p=0.008), when compared to the EES group. Greater improvement amongst EES-HBSO patients was also seen for dyspareunia, non-cyclical dyschaezia and bladder pain. Patients undergoing EES-HBSO had greater improvement in EQ-VAS, although this was no longer statistically significant after controlling for adenomyosis.Conclusion:EES-HBSO appears to provide greater benefit than EES alone for symptoms including non-cyclical pelvic pain as well as for quality-of-life. Further research is required to determine which patients benefit the most from EES-HBSO, and whether removal of the ovaries, uterus or both is the key to this additional benefit in symptom control.

Background:Laparoscopic mesh sacrohysteropexy has been established as an effective, safe, and popular technique to treat uterine prolapse. Nevertheless, recent controversies regarding the role of synthetic mesh in pelvic reconstructive surgery have triggered a trend towards meshless procedures. Other laparoscopic native tissue prolapses techniques such as uterosacral ligament plication and sacral suture hysteropexy have been previously described in literature.Objectives:To describe a meshless minimally invasive technique with uterine preservation, which incorporates steps from the above-mentioned procedures.Materials and Methods:We present a case of a 41-year-old patient with stage II apical prolapse and stage III cystocele and rectocele, who was keen to proceed to surgical management preserving her uterus and avoiding the use of a mesh implant. The narrated video demonstrates the surgical steps of our technique of laparoscopic suture sacrohysteropexy.Main outcome measures:Objective (i.e., anatomic) and subjective (i.e., functional) surgical success on follow-up assessment at least 3 months post-surgery, similarly to every prolapse procedure.Results:Excellent anatomical result and resolution of prolapse symptoms at follow-up appointments.Conclusions:Our technique of laparoscopic suture sacrohysteropexy seems a logical progression in prolapse surgery, responding to patients' wishes for minimally invasive meshless procedures with uterine preservation while at the same time achieving excellent apical support. Its long-term efficacy and safety need to be carefully assessed before it becomes established in clinical practice.Learning objective:To demonstrate a laparoscopic uterine-sparing technique to treat uterine prolapse without the use of a permanent mesh.

Stress urinary incontinence (SUI) is a common condition that for many women requires surgical treatment in order to improve the quality of life following failed conservative therapy. Colposuspension is a long-standing procedure used to treat the condition that has received renewed interest following regulatory and patient concerns about the use of non-absorbable mesh in the form of the synthetic mid-urethral sling (MUS). The abdominal placement of sutures elevating the paravaginal tissues to Cooper's ligament provides urethral support associated with high rates of cure in the short term. The laparoscopic colposuspension is the 21st–century progression of the long-standing open Burch colposuspension. High-quality meta-analysis data support the equivalence of the laparoscopic approach, with recovery and morbidity advantages as compared to an open technique. While such advantages are not evident when comparing laparoscopic colposuspension to the MUS, it appears as effective in the short term and therefore offers a viable alternative, given mesh concerns. The colposuspension procedure by elevation of the paravaginal tissue confers the additional advantage of restoring anterior vaginal wall support. There is a range of approaches and adaptations to the procedure for which evidence is limited and long-term data are lacking. Within this chapter, we introduce the technique and its evolution to the contemporary laparoscopic transperitoneal modified Burch Colposuspension and detail the approach used within our unit. Critical appraisal of the evidence base, alternative techniques, and comparison to other surgical approaches to SUI are then undertaken with specific reference to patient selection and preoperative counselling.

Objective The aim of this study was to assess inter-rater reliability for components of the Visual-Numeric Endometriosis Scoring System (VNESS). VNESS is a novel system for describing surgical findings in each compartment of the pelvis in a way that is simple to use, visually intuitive and mirrors a laparoscopic image of the pelvis. Design Validation study using short surgical laparoscopic video clips. Setting Anonymized video clips of endometriosis surgery scored by 50 Gynaecologists from 12 countries. Population Gynaecologists as scores of short surgical clips selected from a series of endometriosis procedures performed between 2012 and 2022. Methods 50 gynaecologists scored 93 short surgical videoclips using VNESS. 4650 scores were compared against a reference score and analysis was performed to assess inter-rater reliability. Main outcome measures The outcome measures were percentage agreement between given and reference scores, as well as intra-class correlation coefficients (ICC), Cohen Kappa and Quadratic Weighted Kappa Coefficients were calculated to evaluate inter-rater reliability. Results The highest and lowest percentage agreement with the reference score was seen in VNESS 4 (full thickness disease, 97% perfect agreement) and VNESS 1 (superficial disease, 53% perfect agreement) respectively. The intraclass correlation coefficient showed strong inter-rater reliability for all VNESS compartments except the vagina. Conclusions This study suggests that VNESS has excellent inter-observer reliability. Correlation is stronger with more severe disease.

Objective The aim of this study was to assess inter-rater reliability for components of the Visual-Numeric Endometriosis Scoring System (VNESS). VNESS is a novel system for describing surgical findings in each compartment of the pelvis in a way that is simple to use, visually intuitive and mirrors a laparoscopic image of the pelvis. Design Validation study using short surgical laparoscopic video clips. Setting Anonymized video clips of endometriosis surgery scored by 50 Gynaecologists from 12 countries. Population Gynaecologists as scores of short surgical clips selected from a series of endometriosis procedures performed between 2012 and 2022. Methods 50 gynaecologists scored 93 short surgical videoclips using VNESS. 4650 scores were compared against a reference score and analysis was performed to assess inter-rater reliability. Main outcome measures The outcome measures were percentage agreement between given and reference scores, as well as intra-class correlation coefficients (ICC), Cohen Kappa and Quadratic Weighted Kappa Coefficients were calculated to evaluate inter-rater reliability. Results The highest and lowest percentage agreement with the reference score was seen in VNESS 4 (full thickness disease, 97% perfect agreement) and VNESS 1 (superficial disease, 53% perfect agreement) respectively. The intraclass correlation coefficient showed strong inter-rater reliability for all VNESS compartments except the vagina. Conclusions This study suggests that VNESS has excellent inter-observer reliability. Correlation is stronger with more severe disease.

The surgical management of prolapse has undergone a meandering path, with innovation, controversy and legislation all being encountered en route. Some of the dust is now settling with respect to the role of mesh implant surgery, and whilst it continues to have albeit a contracted role, there is very much a new direction set on native tissue and non-mesh repairs with the advent of techniques such as laparoscopic suture hysteropexy, cervicopexy and colporrhaphy.The authors of this paper present the largest series of women undergoing autologous fascia sacrocolpopexy for the treatment of moderate-severe prolapse. Learning from the past, two key questions that must always be answered when evaluating any new procedure are safety and efficacy. For both these measures, the authors show encouraging results comparable with current gold-standard, mesh augmented repairs.The use of autologous fascia has been well established to treat women with urinary incontinence -the pubovaginal / rectus fascial sling (Mcguire EJ et al . Pubovaginal sling procedure for stress incontinence. J Urol. 1978;119:82–4) – the use of which has resurged following the widespread suspension of synthetic sling procedures. Reports of autologous fascial support of the vaginal vault however are limited to a few short-term case series.This series involves 132 women, followed up for a median of 2.2 years; the authors present five-year data with comparable success rates to those reported in the landmark CARE study (Nygaard I, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse.JAMA . 2013 May 15;309(19):2016-24) without the complication of mesh erosion.The mixed bag of patient types and concomitant surgery in this study underscores the myriad of pathology and presenting symptoms to the pelvic floor surgeon; sadly, this reality hinders forensic evaluation of the single procedure. It is noted that around three-quarters of the women in the study were having primary prolapse surgery, with a similar proportion undergoing some form of hysterectomy coupled with autologous fascial vault support. Other sacrocolpopexy series have involved women the majority who have already had primary procedures, are without a uterus and represent an already failed and perhaps more difficult to successfully treat group (Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016 Oct 1;10(10):CD012376.) The addition of a hysterectomy, as well as the harvesting of autologous fascia inevitably means a lengthening of procedure time compared to those usually quoted for women undergoing laparoscopic vault suspension procedures of hysteropexy or sacrocolpopexy.The complexities of pelvic floor patients and their symptoms mean that additionally nearly 2/3 of the patients had Burch colposuspensions performed at the time of index surgery. The unpredictability of pelvic floor surgery on bladder symptoms is amply demonstrated by around 1/3 of women complaining of stress incontinence and a third suffering overactive bladder symptoms following the procedure. It’s clear that functional improvements do not always go hand in hand with anatomical correction for the pelvic floor patient.Many women remain alarmed by the adverse reports of mesh augmentation surgery in gynaecology (Izett-Kay ML, et al ’What research was carried out on this vaginal mesh?’ Health-related concerns in women following mesh-augmented prolapse surgery: a thematic analysis. BJOG . 2021 Jan;128(1):131-139). Contemporary best practice involves distilling out irrefutable principles such as recognising the importance of appropriate apical support which is usually optimally achieved abdominally, as well as an awareness of risks of surgery, careful counselling regarding mesh and being able to offer evidence-based alternatives. This paper provides valuable long-term data for a further promising meshless surgical technique.

Study Objective: To retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis. Design and Setting: Patients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection. Patients: We evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis. Interventions: The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis. Measurements and Main Results: There were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and >= 2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37- 34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03- 33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56- 3.64). Conclusion: Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis. (C) 2022 AAGL. All rights reserved.