Advanced pelvic surgeries, such as radical hysterectomy, deep endometriosis surgery and sacrocolpopexy, pose risks to autonomic pelvic nerves leading to voiding dysfunction and reduced quality of life. This review article evaluates neuropelveological strategies for preventing and managing bladder dysfunction by exploring pelvic neural anatomy, nerve-sparing techniques, and postoperative rehabilitation approaches. Nerve-sparing approaches can reduce postoperative urinary retention and improve recovery of bladder function. Neuromodulation techniques provide additional support in managing persistent voiding dysfunction in selected cases. A multidisciplinary approach integrating detailed knowledge of pelvic neural anatomy, precise surgical techniques and structured postoperative management can minimise bladder dysfunction and optimise patient outcomes.

ABSTRACT Purpose: To compare laparoscopic gynecological surgery training between a developed country’s reference center (host center) and a public reference service in a developing country (home center), and use the technicity index (TI) to compare outcomes and to determine the impact of laparoscopic gynecological surgery fellowship training on the home center’s TI. Methods: The impact of training on the home center was assessed by comparing surgical performance before and after training. TI was assessed in 2017 in the host center, and before and after training in the home center. Epidemiological and clinical data, and information on reason for surgery, preoperative images, estimated intraoperative bleeding, operative time, surgical specimen weight, hospital stay length, complication and reintervention rates were collected from both institutions. Home center pre-training data were retrospectively collected between 2010 and 2013, while post-training data were prospectively collected between 2015 and 2017. A two-tail Z-score was used for TI comparison. Results: The analysis included 366 hysterectomies performed at the host center in 2017, and 663 hysterectomies performed at the home center between 2015 and 2017. TI in the host center was 82.5%, while in the home center it was 6% before training and 22% after training. There were no statistical differences in length of hospital stay, preoperative uterine volume, surgical specimen weight and complication rate between centers. However, significantly shorter mean operative time and lower blood loss during surgery were observed in the host center. Conclusions: High-quality laparoscopic training in a world-renowned specialized center allowed standardizing laparoscopic hysterectomy procedures and helped to significantly improve TI in the recipient’s center with comparable surgical outcomes.

Study Objective: The technical conduct of total laparoscopic hysterectomy (LH) is critical to surgical outcomes. This study explored the validity evidence of an objective scale specific to the assessment of technical skills (H-OSATS) for 7 tasks of an LH with salpingo-oophorectomy procedure performed in the operating room. Design: Observational cohort study. Setting: Two academic hospitals in Marseille and Montpellier, France. Patients: Three groups of operators (novice, intermediate, and experienced surgeons) were video recorded during their live performances of LH on a simple case. For each group, a dozen unedited videos were obtained for the following tasks: division of the round ligament, division of the infundibulopelvic ligament, creation of the bladder flap, opening of the posterior peritoneum, division of the uterine vessels, colpotomy, and closure of the vault. Interventions: Two qualified raters blindly assessed each video using the H-OSATS rating scale. Inter-rater reliability and test-retest reliability were calculated as measures of internal structure. In a separate round of evaluations, the raters provided a global competent/noncompetent decision for each performance. As a measure of consequential validity, a pass/fail score was set for each task using the contrasting group method. Measurements and Main Results: Three tasks (creation of the bladder flap, colpotomy, and closure of the vault) displayed sound validity evidence: a meaningful total score difference among the 3 groups of experience as well as between the intermediate and experienced surgeons, reliability outcomes of > 0.7, and a pass/fail score with a theoretical false-positive rate of < 10%. Conclusion: The validity evidence of the H-OSATS rating scale differed for separate evaluations of the 7 tasks. Three tasks (i.e., creation of the bladder flap, colpotomy, and closure of the vault) revealed sound validity evidence, including at the level of the attending surgeon, whereas other tasks were more consistent with low-stakes formative evaluation standards. (C) 2021 AAGL. All rights reserved.

OBJECTIVE:To demonstrate a modification of the classic Burch procedure, called "laparoscopic transobturator tape (TOT)-like Burch colposuspension." The technique does not involve any type of prosthesis placement, and it is an alternative for patients with stress urinary incontinence in a future without meshes. Describing and standardizing the procedure in different steps makes the surgery reproducible for gynecologists and safe for the patients.DESIGN:Step-by-step educational video, underlining and focusing on the main anatomical landmarks.SETTING:A university tertiary care hospital.INTERVENTIONS:The patient is set under general anesthesia and in lithotomy position. The distinct steps of the procedure are performed as followed: Step 1: Installation. Two 10-mm trocars are positioned in the midline and 2 5-mm trocars in the suprapubic region. The recommended intra-abdominal pressure is 6 to 8 mm Hg, and excessive Trendelenburg is not needed. Step 2: Entry in the Retzius space. The median umbilical ligament and the vesicoumbilical fascia are transected. Step 3: Exposure of the Retzius space and the anatomical structures. The dissection is continued consecutively toward the pubic bone and the Cooper's ligament, laterally toward the external iliac vessels and the corona mortis and medially toward the bladder neck. Step 4: Vaginal dissection. The pubocervical is dissected at the level of the pubourethral ligaments. Step 5: Suspension of the vagina to the Cooper's ligament. In contrast to the standard technique, with the TOT-like Burch, the sutures on the pubocervical fascia are placed at the level of the attachment of the arcus tendinous fascia pelvis and the pubourethral ligament. This way of suspension ensures a lateral traction on the bladder neck, resembling the effect of the TOT, which leads to lower incidence of dysuric symptoms. Step 6: Peritoneal closure.CONCLUSION:The classic colposuspension was created in 1961 for the treatment of stress urinary incontinence prolapse [1]. In the following years, vaginal meshes gained popularity as a treatment option for prolapse and for incontinence owing to their ease of use and satisfying results, which led to a decreased use of the Burch procedure [2,3]. In 2019, the Food and Drug Administration forbid the production of the transvaginal meshes for prolapse [4], an interdiction that could influence the use of synthetic meshes for incontinence in the future [5]. Owing to these recent events, searching for an effective way of management for patients with stress urinary incontinence without any synthetic prostheses, gynecologists have turned back to the 60-year-old Burch colposuspension. One of the drawbacks of the original technique is the high incidence of voiding difficulties-up to 22% [6]. Owing to the knowledge of the exact course of traction with the TOT, in our modified technique, the lateral direction of the suspension provides a tension-free support on the urethra and the bladder neck. The laparoscopic TOT-like Burch colposuspension is a safe and effective treatment for patients with stress urinary incontinence with low rates of dysuric symptoms and represents a valuable alternative for gynecologists in a future without meshes.

STUDY OBJECTIVE:To analyze surgeon views on criteria for a good teaching video with the aim of determining guidelines.DESIGN:An online international survey using a self-developed questionnaire.SETTING:A French university tertiary care hospital.PATIENTS:Three hundred eighty-eight participants answered an online questionnaire (154 women [40.53%] and 226 men [59.47%]).INTERVENTIONS:A questionnaire on the criteria for a good quality teaching surgery video was developed by our team and communicated via an online link.MEASUREMENTS AND MAIN RESULTS:The responses of 388 respondents were analyzed and highlighted the pedagogical benefits of teaching videos. The video duration may vary according to the type of media or surgical procedure but should not exceed 10 to 15 minutes for complex procedures. Providing information on the surgical setup (body mass index of the patient, Trendelenburg position degree, pressure of pneumoperitoneum, etc.) is essential. Surgical videos should be reviewed and divided into clearly defined steps with continued access to the entire nonmodified video for reviewers and be accessible on both educational and open platforms. Patient consent and relevant information should be made available. Reviews should include "bad procedure" videos, which are highly appreciated, especially by young surgeons.CONCLUSION:The many advantages of the video format, including availability and rising popularity, provide an opportunity to reinforce and complement current surgical teaching. To optimize use of this surgical teaching tool, standardization, updating, and ease of access of surgical videos should be promoted.

BACKGROUND:Many studies have demonstrated a link between pelvic floor myofascial syndromes and chronic pelvic pain. Botulinum toxin has been extensively used for several years in the field of pain, especially due to its action on muscle spasm. However, the efficacy of botulinum toxin in the context of chronic pelvic pain remains controversial. OBJECTIVES:This multicentre, randomized, controlled, double-blind study was designed to compare the efficacy of botulinum toxin and local anaesthetic (LA) injection versus LA injection alone for pelvic floor myofascial syndrome and chronic pelvic pain. METHODS:According to the number of painful trigger points detected on physical examination, patients received from 1 to 4 injections of botulinum toxin with LA (BTX) or LA alone. The primary endpoint was Patient Global Impression of Improvement (PGI-I) score on day 60 after infiltration. Secondary endpoints were pain intensity, number of painful trigger points on palpation, analgesic drug consumption and quality of life. RESULTS:We included 80 patients, 40 in each group. This study failed to demonstrate a significant difference between the 2 groups on day 60 in the primary endpoint or secondary endpoints (PGI-I score≤2=20% [LA] versus 27.5% [BTX], P=0.43). However, both groups showed significant alleviation of global pain. CONCLUSION:This study does not justify the use of botulinum toxin in the context of chronic pelvic pain with myofascial syndrome but does justify muscle injections with LA alone. ClinicalTrials.gov: NCT01967524.

Study ObjectiveTo assess the impact of surgical treatment of endometriosis on quality of life and pain over a 3-year period of postoperative follow-up.DesignProspective and multicenter cohort study (Canadian Task Force classification II-2).SettingFive districts including a tertiary referral center and private and general public hospitals.PatientPatients (n = 981), aged 15 to 50years, underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012.InterventionLaparoscopic treatment for endometriosis. All revised American Fertility Society stages were included.Measurements and Main ResultsThe mean visual analog scale score for dysmenorrhea fell from 5.3 ± 3.7 (time 0) to 2.6 ± 3.3 at 6 months, and 2.3 ± 3.3 at 36 months of follow-up (p <.001). Mean visual analog scale scores for chronic pelvic pain and dyspareunia fell from 2.6 ± 3.5 and 2.7 ± 3.2, respectively, before surgery to 1.4 ± 2.5 and 1.1 ± 2.2 at 6 months and then 1.3 ± 2.5 and 1.2 ± 2.3 at 36 months of follow-up. The Short Form 36-Item survey analysis revealed the greatest increases linked to physical domains (i.e., bodily pain and role limitations) from 54.6 ± .9 and 63.3 ± 1.3, respectively, at time 0 to 74.4 ± .9 and 81.9 ± 1.1 at 6 months of follow-up (p <.001), with scores subsequently remaining stable. Among mental domains the most favorable results involved social functioning and role limitations due to emotional problems, which increased from 66 ± .8 and 65.7 ± 1.3 at time 0 to 75.6 ± .9 and 77.4 ± 1.3 at 6 months of follow-up, respectively (p <.001), with scores remaining stable over time.ConclusionsSurgical treatment of endometriosis improves pelvic and sexual pain postoperatively in many women with endometriosis. Improvement later plateaus and remains stable, allowing patients to experience the beneficial effects over a period of years.

STUDY OBJECTIVE:To investigate whether mini-instrumentation may be used for hysterectomy (HT) by all surgeons (assistants and seniors) without increasing the operative time or altering surgeon working conditions. DESIGN:A unicenter, randomized controlled, single blind, parallel, noninferiority trial comparing 2 surgical techniques. SETTING:A tertiary referral center. PATIENTS:Thirty-two patients undergoing HT for a benign gynecologic disease were enrolled in this study in our center between April 2, 2015, and June 1, 2018. Sixteen patients were randomized in group A and 16 patients in group B. INTERVENTIONS:HT with bilateral annexectomy or ovarian conservation using 3-mm instruments (group A) or conventional 5-mm instruments (group B). MEASUREMENTS AND MAIN RESULTS:Concerning the primary outcome, the operative time for the HT 3-mm group was 128 minutes (range, 122-150 minutes) versus 111 minutes (range, 92-143 minutes) for the HT 5-mm group (i.e., δ = 17 [90% confidence interval, -6 to 39]), with rejection of the noninferiority threshold at 35 minutes. Thirty-one percent of HTs initially performed using 3-mm instruments were completed with conventional instruments. HTs performed with mini-instruments required more concentration (p = .02) with surgeons reporting higher levels of frustration (p = .009) and sense of failure (p = .006). Patients tend to experience greater satisfaction regarding scars with a significant difference noted during the postoperative visit both for scar pain (1 vs 4 patients with moderate pain [30-50 mm on the Patient Scar Assessment Scale) in the HT 3-mm group and the HT 5-mm group, respectively) and scar firmness (p = .021; 3 vs 7 patients with moderate firmness [30-50 mm on the Patient Scar Assessment Scale] in the HT 3-mm group and the HT 5-mm group, respectively). CONCLUSION:Total minilaparoscopic HT appears inferior to standard laparoscopy in terms of operative time and surgeon working conditions; only the short-term cosmetic appearance was in favor of the 3-mm approach.

Study ObjectiveLaparoscopic ureteroneocystostomy with a vesicopsoas hitch has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video. We described this procedure in 10 steps, which could help to understand and perform this procedure.MethodsThis video presents an approach to laparoscopic ureteroneocystostomy with a vesicopsoas hitch, which was clearly divided into 10 steps. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. The patient cannot be identified, and she gave informed consent.ResultsThe 10 steps are as follows: step 1, identification of the healthy ureter; step 2, identification of the stenotic part; step 3, section of the ureter; step 4, bladder mobilization; step 5, anterior cystostomy; step 6, psoas hitch; step 7, closure of the anterior cystostomy; step 8, posterior spatulation of the ureter; step 9, cystostomy of the superolateral bladder dome; and step 10, ureteral suture to the bladder.ConclusionLaparoscopic ureteroneocystostomy with a vesicopsoas hitch is an effective technique for intrinsic ureteral endometriosis; it usually needs ureteral resection with end-to-end reanastomosis or reimplantation if the anastomosis is in tension. The 10 steps help to perform each part of surgery in logical sequence, making the procedure faster to adopt and learn. The standardization of laparoscopic techniques could help to reduce the learning curve.

Study ObjectiveLaparoscopic promontofixation has all the advantages of a minimally invasive approach for the treatment of urogenital prolapse. The standardization and description of the technique was the main objective of this video. We describe the complete procedure in 10 steps, which could help to understand and perform this procedure simply, easily, and safely.DesignStep-by-step video demonstration of the technique.SettingA university tertiary care hospital.PatientsPatients with indication for the laparoscopic treatment of urogenital prolapse. The local institutional review board ruled that approval was not required for this video article.Measurements and Main ResultsTen main steps were identified and described in detail during laparoscopic promontofixation: step 1, exposition of the operating field; step 2, dissection of the promontory; step 3, pararectal dissection; step 4, rectovaginal dissection; step 5, vesicovaginal dissection; step 6, supracervical hysterectomy; step 7, fixation of the prosthesis; step 8, peritonization; step 9, fixing the prosthesis to the promontory; and step 10, uterine morcellation.ConclusionLaparoscopic promontofixation is an effective technique for prolapse surgery. The 10 steps help to perform each part of the surgery in logical sequences, making the procedure faster to adopt and easy to learn. Standardization of laparoscopic techniques could help to reduce learning curve.

Abstract Study Objective To report a case of a transrectal mesh erosion as complication of laparoscopic promontofixation with mesh repair, necessitating bowel resection and subsequent surgical interventions. Introduction Sacrocolpopexy has become a standard procedure for vaginal vault prolapse [1], and the laparoscopic approach has gained popularity owing to more rapid recovery and less morbidity [2,3]. Mesh erosion is a well-known complication of surgical treatment for prolapse as reported in several negative evaluations, including a report from the US Food and Drug Administration in 2011 [4]. Mesh complications are more common after surgeries via the vaginal approach [5]; nonetheless, the incidence of vaginal mesh erosion after laparoscopic procedures is as high as 9% [6]. The incidence of transrectal mesh exposure after laparoscopic ventral rectopexy is roughly 1% [7]. The diagnosis may be delayed because of its rarity and variable presentation. In addition, polyester meshes, such as the mesh used in this case, carry a higher risk of exposure [8]. Case Report A 57-year-old woman experiencing genital prolapse, with the cervix classified as +3 according to the Pelvic Organ Prolapse Quantification system, underwent laparoscopic standard sacrocolpopexy using polyester mesh. Subtotal hysterectomy and bilateral adnexectomy were performed concomitantly. A 3-year follow-up consultation demonstrated no signs or symptoms of erosion of any type. At 7 years after the surgery, however, the patient presented with rectal discharge, diagnosed as infectious rectocolitis with the isolation of Clostridium difficile . She underwent a total of 5 repair surgeries in a period of 4 months, including transrectal resection of exposed mesh, laparoscopic ablation of mesh with digestive resection, exploratory laparoscopy with abscess drainage, and exploratory laparoscopy with ablation of residual mesh and transverse colostomy. She recovered well after the last intervention, exhibiting no signs of vaginal or rectal fistula and no recurrence of pelvic floor descent. Her intestinal transit was reestablished, and she was satisfied with the treatment. Conclusion None of the studies that represent the specific female population submitted to laparoscopic promontofixation with transrectal mesh erosion describe the need for more than one intervention or digestive resection [9–12]. Physicians dealing with patients submitted to pelvic reconstructive surgeries with mesh placement should be aware of transrectal and other nonvaginal erosions of mesh, even being rare events. Moreover, they should perform an active search for unusual gynecologic and anorectal signs and symptoms. Most importantly, patients undergoing mesh repair procedures must be warned of the risks of the surgery, including the possibility of several subsequent interventions.

In recent years, training and education in endoscopic surgery has been critically reviewed. Clinicians, both surgeons as gynaecologist who perform endoscopic surgery without proper training of the specific psychomotor skills, are at higher risk to increased patient morbidity and mortality. Although the apprentice-tutor model has long been a successful approach for training of surgeons, recently, clinicians have recognised that endoscopic surgery requires an important training phase outside the operating theatre. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) recognises the necessity of this structured approach and implements two separated stages in its learning strategy. In the first stage, a skill certificate on theoretical knowledge and specific practical psychomotor skills is acquired through a high-stake exam; in the second stage, a clinical programme is completed to achieve surgical competence and receive the corresponding diploma. Three diplomas can be awarded: (a) the Bachelor in Endoscopy, (b) the Minimally Invasive Gynaecological Surgeon (MIGS) and (c) the Master level. The Master level is sub-divided into two separate diplomas: the Master in Laparoscopic Pelvic Surgery and the Master in Hysteroscopy. The complexity of modern surgery has increased the demands and challenges to surgical education and the quality control. This programme is based on the best available scientific evidence, and it counteracts the problem of the traditional surgical apprentice-tutor model. It is seen as a major step toward standardisation of endoscopic surgical training in general.

AIMS Pelvic exposure is one of the most important issues in laparoscopic surgery. The aim of this prospective study was to evaluate if surgical experience could influence the Trendelenburg position (head down position) during pelvic laparoscopic surgery. METHODS Between 1st January and 28 February 2014, all the pelvic laparoscopic surgeries performed at our Institution were involved. Surgical expertise was arbitrarily defined considering the number of years performing laparoscopic surgeries (resident, junior ≤10 years and expert >10 years). Basal Trendelenburg position was measured in degree when an adequate visualization (small bowel and sigmoid colon displaced out of the pelvis) was obtained before the beginning of the surgery: each variation was registered and motivated. Age, ASA risk, BMI, type of surgery, maximum end-tidal CO2, maximum peak inspiratory pressure, intraoperative pneumoperitoneum pressure were registered. RESULTS 97 patients were enrolled with a mean age of 44.1 years and mean BMI of 24.3. ASA risk was 1 in 54.6% of the patients (53/97), 2 in 40.2% (40/97) and 3 in 4.2% (4/97). Surgical procedures were hysterectomy in 31.6% (30/97), adnexiectomy in 31.6% (30/97), surgery for endometriosis in 22.1% (21/97), hysterectomy + vaginal cuff promontofixation in 11.6% (11/97) and others (myomectomy or diagnostic laparoscopy) in 5.1% (5/97). Surgeries were performed in 43.2% of the cases by expert, in 45.3% by juniors and in 11.6% by residents. Patients' surgical factors are reported in table 1. On average, the pneumoperitoneum pression was 12 mmHg, the peak inspiratory pressure was 27,5 and the maximum end-tidal CO2 was 38,3. The mean basal Trendelemburg position angle was 18.5°. In 52.6% of the surgeries at least one change of Trendelenburg position was necessary, with a maximum of 7 changes. The most frequent reason for changing was the improvement of visualization. In 10.3% of the surgeries, Trendelemburg position exceeded 25° at some point of the surgical procedure. No difference in mean Trendelemburg position was seen considering laparoscopic surgical expertise (seniors 18.9°, juniors 18.2° and residents 17.7°, p 0.49) or the type of surgery (p 0.096). CONCLUSIONS Surgical expertise does not affect the Trendelemburg position during laparoscopic surgery. An adequate pelvic visualization can be commonly obtained with a moderate Trendelenburg position angle (18.5°), regardless the complexity of surgical procedure. The modification of the Trendelemburg position during the surgical procedure allows the surgeon to adapt the pelvic visualization to the surgery-related anatomical changes.

Hysteroscopic reliability may be influenced by the experience of the operator and by a lack of morphological diagnostic criteria for endometrial malignant pathologies. The aim of this study was to evaluate the diagnostic accuracy and the inter-observer agreement (IOA) in the management of abnormal uterine bleeding (AUB) among different experienced gynecologists.

Study ObjectiveTo describe a technique for the safe placement of retropubic midurethral slings in patients undergoing concomitant laparoscopic surgery in order to avoid major complications associated with this procedure such as bladder perforation and retropubic hematomas.DesignStep-by-step video demonstration of the technique.SettingA university tertiary care hospital.PatientsPatients with an indication for retropubic midurethral sling placement because of recurrent stress urinary incontinence, intrinsic sphincter deficiency, or severe pelvic organ prolapse in whom a concomitant laparoscopic surgery has to be performed for other medical conditions.InterventionLaparoscopic opening and dissection of the Retzius space and insertion of the sling under a laparoscopic view of this space.Measurements and Main ResultsThis technique has been mainly used in patients undergoing laparoscopic pelvic organ prolapse repair. No complications have been identified so far, even in high-risk patients such as those with previous Burch colposuspension.ConclusionThis is a simple and reproducible technique for preventing major complications associated with retropubic sling placement in patients undergoing laparoscopic surgery for other reasons. It also permits the immediate detection and even resolution of complications in case any arise. Even high-risk patients may be safely approached.