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BACKGROUND: During laparoscopic hysterectomy (LH), the elevation of intra-abdominal and intra-thoracic pressures due to pneumoperitoneum (PP) results in an increase in intracranial pressure (ICP). The Trendelenburg position (TP) is an accentuating factor. This trial aimed to assess the effect of intravenous (IV) lidocaine infusion on optic nerve sheath diameter (ONSD), a widely accepted surrogate measure for ICP, during PP and TP. METHODS: A randomized, placebo-controlled study was conducted on 66 patients scheduled for LH, equally divided into a lidocaine group and a saline group. ONSD, the primary outcome, was recorded before induction (T1), before PP initiation in the supine position (T2), five minutes (T3), 30 minutes (T4), and 60 minutes (T5) after PP and TP, and five minutes after termination of PP in the supine position (T6). Secondary outcomes included numerical rating scale (NRS) scores at arrival to the post-anesthesia care unit (PACU), 6, 12, and 24 hours after surgery, and postoperative adverse effects. RESULTS: ONSD at T4 and T5 was significantly lower in the lidocaine group than in the saline group (T4: 4.94±0.43 mm vs. 5.27±0.37 mm; P =0.003, T5: 5.08±0.46 vs. 5.41±0.38 mm; P =0.004). The lidocaine group had significantly lower NRS values than the saline group only at PACU arrival (median [Q1-Q3]: 5 [4-6] vs. 6 [5-6.25]; P =0.016). Fewer patients in the lidocaine group experienced postoperative headache (P =0.029). CONCLUSIONS: IV lidocaine during LH can attenuate the ONSD distension, decrease pain scores at PACU arrival, and reduce the incidence of postoperative headache.

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BACKGROUND: Yolk sac tumor (YST) is a highly malignant germ cell tumor, a majority of which originate from the gonads and are extremely rare from endometrium. CASE PRESENTATION: Here we present a case of a 42-year-old woman suffered from primary pure yolk sac tumor of the endometrium complicated with situs inversus totalis. The patient presented at our hospital with irregular vaginal bleeding. Imageological examination showed a space-occupying lesion in the cervix and the serum Alpha-fetoprotein (AFP) level was significantly high (more than 1210ng/ml). Then she underwent total hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection. The subsequent postoperative pathological diagnosis was yolk sac tumor arising from the endometrium. Next, the patient was treated with 6 cycles of chemotherapy with Pingyangmycin, etoposide and cisplatin regimen and was alive without evidence of recurrence or distant metastases for 13 months. CONCLUSIONS: This rare disease needs to be differentiated from endometrial epithelial neoplasia and the significant increase in AFP is helpful for diagnosis. Combined with previous literature reports, comprehensive staging laparotomy or maximum cytoreductive surgery complemented by standard chemotherapy can usually achieve a good efficacy.

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This study aimed to develop a predictive tool for surgical site infections (SSI) following hysterectomy and propose strategies for their prevention and control. We conducted a retrospective analysis at a tertiary maternity and child specialist hospital in Zhejiang Province, focusing on patients who underwent hysterectomy between January 2018 and December 2023 for gynecological malignancies or benign reproductive system diseases resistant to medical treatment. Risk factors associated with surgical site infections (SSI) following hysterectomy were identified using LASSO regression analysis on data from 2018 to 2022 as the training set. Independent risk factors were then used to develop a nomogram. The model was validated using data from 2023 as the validation set. Model performance was assessed using the area under the receiver operating characteristic curve (ROC), while calibration curves were employed to gauge model accuracy. Furthermore, clinical utility was evaluated through clinical decision curve analysis (DCA) and clinical impact curve analysis (CIC), providing insights into the practical application of the nomogram. Multivariate analysis identified six independent risk factors associated with SSI development after hysterectomy: BMI ≥ 24 kg/m2 (OR: 2.58; 95% CI 1.14-6.19; P < 0.05), hypoproteinaemia diagnosis (OR: 4.99; 95% CI 1.95-13.02; P < 0.05), postoperative antibiotic use for ≥ 3 days (OR: 49.53; 95% CI 9.73-91.01; P < 0.05), history of previous abdominal surgery (OR: 7.46; 95% CI 2.93-20.01; P < 0.05), hospital stay ≥ 10 days (OR: 9.67; 95% CI 2.06-76.46; P < 0.05), and malignant pathological type (OR: 4.62; 95% CI 1.78-12.76; P < 0.05). A nomogram model was constructed using these variables. ROC and calibration curves demonstrated good model calibration and discrimination in both training and validation sets. Analysis with DCA and CIC confirmed the clinical utility of the nomogram. Personalized nomogram mapping for SSI after hysterectomy enables early identification of high-risk patients, facilitating timely interventions to reduce SSI incidence post-surgery.

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BACKGROUND: To the best of our knowledge, no population-based studies have provided insights into the prevalence of hysterectomy and its risk factors among northern Iranian females. Thus, the present study aimed to investigate the prevalence and sociodemographic determinants of hysterectomy in a large cohort of northern Iranian females. METHODS: This cross-sectional study included data from the enrollment phase of the Tabari cohort study (TCS). The TCS consists of 10,255 adults (4,149 males and 6,106 females) aged 35-70 years who reside in Sari, Mazandaran, Iran, of which 6103 females were included in the study. Multiple logistic regression analysis was used to search for hysterectomy determinants. RESULTS: Our results revealed that the prevalence of hysterectomy among northern Iranian females was 9.7% (595/6103). Additionally, 50-59 (OR: 4.63, 95% CI: 3.57-6.01) and 60-70 (OR: 5.83, 95% CI: 4.28-7.95) age groups, higher socioeconomic levels (OR: 1.66, 95% CI: 1.13-2.42), a history of tubectomy (OR: 1.27, 95% CI: 1.05-1.53), and more gravida (OR: 5.35, 95% CI: 1.62-17.63) were found to increase the odds of hysterectomy, whereas living in mountainous areas (OR: 0.57, 95% CI: 0.43-2.75) and having a job (OR: 0.62, 95% CI: 0.45-0.86) were found to decrease the odds of hysterectomy. CONCLUSION: Older age groups, living in urban areas, higher socioeconomic levels, not having a job, a history of tubectomy, and more gravida were found to increase the odds of hysterectomy.

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BACKGROUND: Despite being a highly debated issue, subtotal or supracervical hysterectomy (SCH) is still considered a safe and effective treatment for women with benign gynecological lesions. Benign and malignant cervical diseases have been reported after SCH, with fibroids being the most frequently diagnosed lesions in the excised cervical stump. Recurrence of cervical disease after SCH usually presents with vaginal bleeding, pelvic mass, or abdominal pain; moreover, it may necessitate reoperation and resection of the cervical stump or trachelectomy. Trachelectomy is known to be a difficult surgical procedure that may be associated with significant intra- and post-operative morbidity. CASE PRESENTATION: We presented here a case of a 41-year-old nulliparous woman with a pelvic mass related to the cervical stump presented 2 years after subtotal hysterectomy, performed due to interactable abnormal uterine bleeding, which was attributed to a multiple fibroid uterus. Six years ago, she complained of pelvic pain, excessive vaginal discharge, and spotting. A transvaginal sonography and magnetic resonance imaging with contrast were performed, which revealed a 10.2 × 7.6 × 6.5 cm heterogeneous pelvic mass with irregular borders and marked vascularity on color Doppler. Surgical exploration and resection of the mass with cervical stump excision were performed. Histopathology confirmed the diagnosis of cervical stump multiple benign leiomyomata with no atypical features. CONCLUSION: Recurrence or De novo development of leiomyomata and other cervical lesions might occur after supracervical or subtotal hysterectomy; thus, thorough pre-operative counseling for women requesting a SCH regarding the pros and cons of the procedure compared with total hysterectomy should be optimized. Meticulous follow-up, including the continuation of routine cervical cytological smears, is mandatory for patients with a retained cervix.

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OBJECTIVES: To investigate the clinicopathological characteristics and prognosis of patients with uterine sarcoma treated following surgery for presumed benign disease. METHODS: We identified all patients with uterine sarcoma found incidentally after primary surgery for presumed benign disease who presented to our institution and received re-exploration for completion surgery from January 1, 2004 to January 1, 2021. We analyzed the clinicopathological characteristics and prognosis. RESULTS: Overall, 95 patients were included in our study. For the initial surgery, myomectomy was performed in 50 (52.6%, 50/95) patients, hysterectomy was performed in 45 (47.4%, 45/95) patients. All patients were re-explored to complete the staging operation. The median time to the staging surgery was 40 days (range 15-90 days). There were 29 patients (30.5%, 29/95) had remnant sarcomas, with 17 patients (17/95, 17.9%) on the remaining uterus, 9 patients (9/95, 9.5%) had disseminated diseases, and 4 patients (4/95, 4.2%) had positive lymph nodes. About 40 patients (42.1%) received adjuvant chemotherapy, 55.2% (16/29) and 36.4% (24/66) patients with/without remnant diseases received adjuvant chemotherapy, respectively (P = 0.087). The median follow-up duration was 76.7 months (IQR: 34.8-118.1 months). And 17 patients (17.9%) had recurrence following re-exploration surgery. 5-year progression-free survival (PFS) and 5-year overall survival (OS) for the entire cohort was 81.7% and 92.1%, respectively. Patients with remnant sarcomas had a tendency towards a worse 5-year PFS and 5-year OS, compared with those without (5-year PFS: 75.6% vs. 84.5%, P = 0.224; 5-year OS: 85.5% vs. 95.1%, P = 0.217). Patients with disseminated diseases had a worse 5-year OS (62.5% vs. 95.1%, P = 0.007) and non-significantly worse 5-year PFS (64.8% vs. 83.4%, P = 0.153) compared with those without. CONCLUSIONS: Patients with uterine sarcoma treated following surgery for presumed benign disease have a favorable survival. Patients with disseminated diseases had a worse 5-year OS compared with those without. Surgical re-exploration may be valuable for removing remnant sarcomas and disseminated diseases.

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To compare the clearance rate of high-risk human papillomavirus (HR-HPV) in patients with high-grade squamous intraepithelial lesion (HSIL) after 2 different treatments (conization vs hysterectomy), and investigate the influencing factors. A retrospective cohort was established in HSIL patients with HR-HPV infection treated with conization or hysterectomy from July 2020 to May 2022. Age matching (1:1) was conducted between conization group and hysterectomy group. Chi-square test and t-test were employed to compare baseline and clinical characteristics between the 2 groups (conization vs hysterectomy). In addition, univariate and multivariate logistic regression analyses were conducted to compare the influencing factors for HR-HPV clearance at 6 months after surgery. The HR-HPV clearance rates at 6 months were 70.6% and 73.8% in conization group and hysterectomy group in the matched groups, respectively (P = .755). Similarly, at 12 months, the clearance rates were 78.6% and 76.5% in the matched groups, respectively (P = .844). Considering different age groups among all patients, the HR-HPV clearance rates were 81.8%, 72.9%, 73.5%, and 53.6% in the 20 to 30-year, 31 to 40-year, 41 to 50-year and 51 to 60-year groups at 6 months, respectively, and the clearance rates were 87.5%, 80.6%, 84.5% and 52.9% at 12 months, respectively. For HSIL, the postoperative HPV clearance rates were similar between the 2 groups (conization vs hysterectomy), conization is enough to resect the lesion and eliminate HPV. In addition, we should pay attention to the postoperative HR-HPV status in the older population of the 2 groups.

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The current review described a 55-year woman using 28 months to finish her surgery-based radiation-free multimodality treatment journey to fight International Federation of Gynaecology & Obstetrics (FIGO) 2018 clinical stage IIA2 (cT2aN0M0) squamous cell carcinoma (SCC) of the cervix. She received six cycles of perioperative adjuvant therapy, including three cycles of neoadjuvant therapy (NAT) and three cycles of postoperative adjuvant therapy by using combination of dose-dense chemotherapy (CT, weekly paclitaxel 80 mg/m2+triweekly cisplatin 40 mg/m2), immunotherapy (IO, triweekly pembrolizumab 200 mg) and half-dose anti-angiogenic agent (triweekly bevacizumab 7.5 mg/kg) plus interval radical surgery (radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para-aortic lymph node sampling) and following maintenance therapy with monthly 22 cycles of half-dose of IO (pembrolizumab 100 mg) and concomitant 4 cycles of single-agent CT (paclitaxel 175 mg/m2) and 18 cycles of half-dose anti-angiogenic agent (bevacizumab 7.5 mg/kg). During the cervical SCC fighting journey, two unwanted adverse events (AEs) occurred. One was pseudo-progressive disease during the NAT treatment and pathology-confirmed upgrading FIGO stage IIIC1p (ypT2a1N1M0) after radical surgery and the other was the occurrence of hypothyroidism during the post operative adjuvant therapy. Based on this case we presented, we review the recent trend in the management of women with locally advanced cervical cancer (LACC) using the radiation-free but surgery-based multimodality strategy and highlight the strengths and limitations about perioperative adjuvant therapy with dose-dense CT + IO + half-dose anti-angiogenic agent and maintenance treatment of half-dose IO combining with short-term single agent CT and following long-term half-dose anti-angiogenic agent. All underscore the possibility that women with LACC have an opportunity to receive surgery-based RT-free multi-modality strategy to manage their diseases with satisfactory results. Additionally, the evolving role of IO plus CT with/without anti-angiogenic agent functioning as either primary treatment or adjuvant therapy for the treatment of advanced CC has been in process continuously. Moreover, the patient's positive response to IO, pembrolizumab as an example, both during the primary and maintenance therapy, highlights the importance of integrating IO into CT regimens for CC, especially in cases where conventional therapies, RT as an example, are insufficient or who do not want to receive RT-based treatment. The sustained disease-free status of the patient over several years reinforces the potential of IO to significantly increase long-term survival outcomes in CC patients, particularly for those with LACC.

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OBJECTIVE: Endometrial cancer (EC) is the most common gynecological malignancy in high-income countries. In Taiwan, the incidence of EC increased from 1.69 in 1980 to 11.36 per 100,000 women/year in 2010. Therefore, we aimed to study the prognostic factors and survival of patients with EC in southern Taiwan. MATERIALS AND METHODS: This study included patients with EC who underwent hysterectomy-based surgery at our hospital between 2010 and 2020. The primary outcome was 5-year progression-free survival (PFS) and overall survival (OS) of patients diagnosed with EC. The secondary outcome was the prognostic factors associated with 5-year PFS and OS in patients with EC. We used the chi-square test to assess categorical variables and the independent t-test to assess continuous variables. The Kaplan-Meier method was used to estimate survival outcomes. Cox regression analysis was conducted to examine the factors associated with PFS and OS. RESULTS: A total of 133 patients were enrolled in this study. The mean age of the patients was 56.5 ± 10.71 years. The mean body mass index was 26.4 ± 5.21 kg/m2. The 5-year PFS and OS were 90.3% and 94.53%, respectively. In terms of PFS, endometrioid histology was linked to more favorable outcomes (hazard ratio [HR] = 0.02, 95% confidence interval [CI]:0.001-0.59), while lymph-vascular space invasion (LVSI) was associated with adverse results (HR = 9.11, 95% CI: 1.07-77.44). Initial analyses revealed no significant correlations between OS and various factors, including age, BMI, parity, DM, hypertension, age at last birth, and tumor grade. However, univariate analysis found grade 3 tumor differentiation, LVSI, and lymph node invasion associated with poorer OS. Laparoscopy was associated with better OS. Nevertheless, subsequent multivariate analysis did not reveal any factor significantly associated with OS. Most patients with EC (76.69%) underwent laparoscopic surgery. CONCLUSION: In conclusion, endometrioid histology was linked to more favorable PFS, while LVSI was related to adverse PFS. Our study did not identify any factors associated with OS. Two-thirds of the patients underwent minimally invasive surgery.

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Ovariohysterectomy is a common surgical procedure in pet rabbits and one of its potential complications is postoperative gastrointestinal stasis, possibly exacerbated by prolonged surgery time. The objective of this prospective clinical study was to compare two techniques for surgical haemostasis with respect to procedural duration, postoperative pain, and return of gastrointestinal function, in 22 female rabbits undergoing ovariohysterectomy. Rabbits were assigned to one of two groups: conventional vessel ligation (CVL) and haemostasis with a vessel sealing device (VSD). The outcome variables for comparison between the two groups, recorded at 60-, 120-, 180-, and 360-minutes post anaesthesia, were duration of anaesthesia and surgery, postoperative Rabbit Grimace Scale scores, and measured food intake and faecal output. The vessel sealing device caused no appreciable blood loss. The duration of both surgery and anaesthesia was shorter in group VSD (20 ± 4 and 31 ± 6 minutes, respectively) than in group CVL (43 ± 9 and 54 ± 9 minutes, respectively) (p < 0.001). There were no differences between groups in time elapsed from the end of anaesthesia to both first food intake and first defecation. In both groups, the score of the Rabbit Grimace Scale decreased over time with statistically significant differences between 60 minutes and all the subsequent time points (p < 0.001). Vessel sealing devices may be recommended over conventional haemostasis for rabbit ovariohysterectomy to decrease the duration of surgery and anaesthesia, with potential beneficial effects on sustainability and practice workflow.

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BACKGROUND: Angioleiomyoma, a benign tumour composed of smooth muscle cells and thick-walled vessels, is expected to be very rare in the female genital tract. This study aimed to describe the clinicopathological features and treatment outcomes of angioleiomyoma in the female genital tract. METHODS: We retrospectively reviewed 89 women with angioleiomyoma in the genital tract who were treated at Third Xiangya Hospital of Central South University between July 2008 and October 2023. Symptom remission rate was the primary outcome of the study. RESULTS: Angioleiomyomas accounted for 0.6% of leiomyomas of the female genital tract. The average age of the 89 women was 41.8 ± 8.7 years. Seventy women (78.7%) had a history of uterine surgery, of whom two patients had removed uterine angioleiomyoma by laparoscopic myomectomy. The angioleiomyomas of 61 (68.5%) women were located in the uterine corpus, 17 (19.1%) in the broad ligament, 10 (11.2%) in the cervix and only 1 (1.1%) in the vagina. Abnormal uterine bleeding was the main clinical manifestation of angioleiomyomas located in the uterine corpus or cervix, whereas the main clinical manifestation of angioleiomyomas in the broad ligaments was pelvic mass. Of the 89 women, 59 underwent surgery to preserve the uterus, and 30 underwent total hysterectomy or subtotal hysterectomy. The intraoperative blood loss was more than 500 ml (700-4,500 ml) in six women. The symptom remission rate was 100% after surgery. Among the 59 women with preserved uterus, 8 showed multiple uterine leiomyomas during follow-up, but it was difficult to determine whether they were angioleiomyomas. Angioleiomyomas recurred in one women who underwent total hysterectomy. CONCLUSION: Angioleiomyoma is rare in the female reproductive tract, and patients may present with diverse symptoms, which are related to the location of the tumour. Hysterectomy and myomectomy are both effective treatment methods, but the risk of intraoperative bleeding should be recognised for multiple lesions and those with large diameters. Relapse may occur in some patients.

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OBJECTIVE: The objective of this study was to assess the oncologic outcome of surgically-treated patients with early-stage, intermediate-risk cervical cancer according to postoperative therapy modality. METHODS: This retrospective cohort study queried the Japanese Gynecologic Oncology Group's nationwide surgical data platform. The study population was 1084 patients with stage IB cervical cancer who underwent primary radical hysterectomy and lymphadenectomy from 2004 to 2008. Histology type-incorporated intermediate-risk factor patterns were clustered into three groups based on recurrence risk. Oncologic outcomes were assessed per postoperative therapy: external beam radiotherapy alone, concurrent chemo-radiotherapy, chemotherapy alone, and no treatment. RESULTS: Histology-incorporated intermediate-risk groups included: no lympho-vascular space invasion in any histology, or squamous cell carcinoma with lympho-vascular space invasion but no deep stromal invasion (n=559, 51.6%, group 1); squamous cell carcinoma with both lympho-vascular space invasion and deep cervical stromal invasion (n=281, 25.9%; group 2); and non-squamous histology with lympho-vascular space invasion (n=244, 22.5%; group 3). The 5-year disease-free survival rates were 93.3%, 89.3%, and 82.5% for group 1,-2, and -3, respectively (p<0.001), with group 3 exhibiting an almost three-fold increased recurrence risk compared with group 1 (adjusted-hazard ratio (aHR) 2.70, 95% confidence interval (CI) 1.70-4.32), followed by group 2 (aHR 1.67, 95% CI 1.01 to 2.75). Disease-free survival was similar across the postoperative therapy groups: 5 year rates for external beam radiotherapy alone, concurrent chemo-radiotherapy, chemotherapy alone, and no postoperative treatment, 94.8%, 87.2%, 93.6%, and 94.2% for group 1 (p=0.294); 85.0%, 93.3%, 87.3%, and 90.5% for group 2 (p=0.578); and 85.4%, 83.1%, 80.5%, and 83.3% for group 3 (p=0.876). The aHR for disease-free survival comparing no postoperative treatment to external beam radiotherapy alone was 1.10 (95% CI 0.37 to 3.28), 0.71 (95% CI 0.29 to 1.79), and 1.21 (95% CI 0.42 to 3.51) for group 1, group 2, and group 3, respectively. The observed exposure-outcome associations were similar for cause-specific survival (all, p>0.05). CONCLUSION: In this retrospective investigation in Japan, active surveillance without postoperative therapy following radical hysterectomy and lymphadenectomy was not associated with oncologic outcome in early-stage, intermediate-risk cervical cancer.

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OBJECTIVE: To determine the rate of avoidable admissions following anticipated same-day discharge for patients undergoing minimally invasive hysterectomy and to identify risk factors associated with such admissions. METHODS: A retrospective review was performed of patients who underwent a minimally invasive hysterectomy between March 2019 and July 2021 for a suspected gynecologic malignancy at a single tertiary care center. Pre-operatively, patients were assessed for same-day discharge versus planned admission. Reasons for day-of-surgery admission despite anticipated same-day discharge were categorized as anesthesia-related, system issues, intra-operative factors, post-operative pain, and social factors. Patients deemed not candidates for same-day discharge were defined as planned admissions. Indications were categorized as necessary or potentially avoidable. Descriptive and comparative statistics were used to summarize the cohort. RESULTS: In total, 372 patients were identified: 261 (70.2%) anticipated same-day discharges and 111 (29.8%) planned admissions. Of anticipated same-day discharges, 230/261 (88.1%) were successfully discharged, while 31/261 (11.9%) required admission. Reasons for unplanned admissions were anesthesia-related (14/31, 45.2%), system issues (7/31, 22.6%), intra-operative factors (5/31, 16.1%), post-operative pain (3/31, 9.7%), and social factors (2/31, 6.5%). Among the 111 pre-operatively planned admissions, 81 (73.0%) were necessary due to comorbidities or surgical complexity, while 30 (27.0%) were potentially avoidable because patients could have been optimized for same-day discharge. Opportunities for optimization pre-operatively included comorbidities (13/30, 43.3%), system issues (8/30, 26.7%), social factors (6/30, 20.0%), and provider preference (3/30, 10.0%). CONCLUSION: Most patients undergoing minimally invasive hysterectomy can be safely discharged the same day. Potentially avoidable admissions were primarily related to patient comorbidities that can be better optimized pre-operatively.

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The position of the internal os of the cervix reported in the literature was inconsistent on MRI images. Additionally, the practical impactful data influencing the internal os located by MRI is limited. We aimed to confirm the position of the internal os of the cervix on MRI images, and the influencing factors locating the the internal os by MRI. A single-center retrospective study was conducted. Data from 175 patients who underwent total hysterectomy for stage I endometrial cancer were collected. The internal os of the cervix is positioned as the starting point for measuring the length of the cervix on MRI images. On dynamic contrast-enhanced MRI (DCE-MRI), the section formed by the enhancement difference between the uterus and cervix, and on T2-weighted imaging(T2WI), the section formed by the physiological curvature of the uterus and the low signal intensity of the cervical stroma were used as starting points. The results showed no statistically significant difference compared with the removed uterus specimens (p = 0.208, p = 0.571, p = 0.804). A history of cesarean section(p < 0.001), irregular vaginal bleeding for more than three months(p < 0.001), cervical adenomyosis(p = 0.043), and premenopause(p = 0.001) were not conducive to locating the internal os of the cervix by MRI. Our findings provide valuable information and confirm the position of the internal os of the cervix on MRI images, and the several important infuencing factors. We hope that some patients will benefit from our study.

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The proportion of women experiencing premature menopause is on the rise in India, particularly in the age groups of 30-39 years. Consequently, there is a need to understand the factors influencing the prevalence of premature menopausal status among women. Our study uses the data from 180,743 women gathered during the latest Indian version of the Demography Health Survey (National Family Health Survey-5). Our results suggest that close to 5% of women in rural areas and 3% of women in urban areas experience premature menopause, and this figure varies across Indian States. The regression results show that surgical menopause, lower levels of education, poorer wealth index, rural residence, female sterilization, and insurance coverage are key drivers of premature menopause. One of the striking factors is that the prevalence of premature menopause among those with the lowest levels of education (6.85%) is around seven times higher than those with the highest level of education (0.94%). We conducted a decomposition analysis to delve into the factors contributing to this inequality. The results show that undergoing a hysterectomy (surgical menopause) account for 73% of the gap in premature menopausal rates between women with the lowest and highest levels of education. This indicates that women with poor education are more likely to undergo hysterectomy at a younger age. This finding warrants further exploration as we would expect that women from lower socio-economic background would have limited access to surgical care, however, our results suggest otherwise. This perhaps indicates a lack of awareness, lack of alternative treatment options, and over-reliance on surgical care while neglecting conservative management. Our results have implications for addressing the diverse needs of the increasing number of women in their post-menopause phase and for focusing on conservative treatment options for these women.

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INTRODUCTION: The objective of this study was to determine the trends in benign surgery in GO practice across the United States. METHODS: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2021. Subjects were selected by filtering for cases of hysterectomy using current procedural terminology (CPT codes). Trends over time were assessed using linear regression for continuous outcomes and logistic regression for categorical outcomes. RESULTS: From the 2015 to 2021, the dataset contained 246,743 hysterectomies that were performed across the United States. For all gynecologic specialties, 188,534 (76%) were performed for benign indications and 59,209 (24%) were gynecologic cancer cases. The proportion of hysterectomies done by all specialists for benign indications increased with increasing year. When looking at hysterectomy cases by surgeon's subspecialty, GOs performed 35,680 (23%) of all benign cases over the entire time period. Over our study time period, the proportion of benign hysterectomies performed by GOs increased with increasing year with the proportion of benign hysterectomies done by GO in 2016 was 37.8% and reached 45.2% in 202. The proportion of hysterectomies done by all sub-specialists for cancer indications decreased with increasing year including the proportion of cancer cases performed by GOs for cancer indications. CONCLUSIONS: The proportion of benign hysterectomies performed by GO consistently increased every year. This study corroborates existing survey data and hypothesizes that the practice of GO is increasingly being consumed by general gynecology.

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Pseudo-Meigs syndrome is a rare syndrome characterized by hydrothorax and ascites associated with pelvic masses, and patients occasionally present with elevated serum cancer antigen-125 (CA125) levels. Hydropic leiomyoma (HLM) is an uncommon subtype of uterine leiomyoma characterized by hydropic degeneration and secondary cystic changes. Rapidly enlarging HLMs accompanied by hydrothorax, ascites, and elevated CA125 levels may be misdiagnosed as malignant tumors. Here, we report a case of HLM in a 45-year-old Chinese woman who presented with ascites and hydrothorax. Preoperative abdominopelvic CT revealed a giant solid mass in the fundus uteri measuring 20 × 15 × 12 cm. Her serum CA125 level was elevated to 247.7 U/ml, while her hydrothorax CA125 level was 304.60 U/ml. The patient was initially diagnosed with uterine malignancy and underwent total abdominal hysterectomy and adhesiolysis. Pathological examination confirmed the presence of a uterine hydropic leiomyoma with cystic changes. After tumor removal, the ascites and hydrothorax subsided quickly, with no evidence of recurrence. The patient's serum CA125 level decreased to 116.90 U/mL on Day 7 and 5.6 U/mL on Day 40 postsurgery. Follow-up data were obtained at 6 months, 1 year, and 2 years after surgery, and no recurrence of ascites or hydrothorax was observed. This case highlights the importance of accurate diagnosis and appropriate management of HLM to achieve successful outcomes.

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BACKGROUND: As a minimally invasive technique, robot-assisted hysterectomy (RAH) offers surgical advantages and significant reduction in morbidity compared to open surgery. Despite the increasing use of RAH in benign gynaecology, there is limited data on its cost-effectiveness, especially in a European context. Our goal is to assess the costs of the different hysterectomy approaches, to describe their clinical outcomes, and to evaluate the impact of introduction of RAH on the rates of different types of hysterectomy. METHODS: A retrospective single-centre cost-analysis was performed for patients undergoing a hysterectomy for benign indications. Abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), laparoscopically assisted vaginal hysterectomy (LAVH) and RAH were included. We considered the costs of operating room and hospital stay for the different hysterectomy techniques using the "Activity Centre-Care program model". We report on intra- and postoperative complications for the different approaches as well as their cost relationship. RESULTS: Between January 2014 and December 2021, 830 patients were operated; 67 underwent VH (8%), 108 LAVH (13%), 351 LH (42%), 148 RAH (18%) and 156 AH (19%). After the implementation and learning curve of a dedicated program for RAH in 2018, AH declined from 27.3% in 2014-2017, to 22.1% in 2018 and 6.9 % in 2019-2021. The reintervention rate was 3-4% for all surgical techniques. Pharmacological interventions and blood transfusions were performed after AH in 28%, and in 17-22% of the other approaches. AH had the highest hospital stay cost with an average of €2236.40. Mean cost of the hospital stay ranged from €1136.77-€1560.66 for minimally invasive techniques. The average total costs for RAH were €6528.10 compared to €4400.95 for AH. CONCLUSION: Implementation of RAH resulted in a substantial decrease of open surgery rate. However, RAH remains the most expensive technique in our cohort, mainly due to high material and depreciation costs. Therefore, RAH should not be considered for every patient, but for those who would otherwise need more invasive surgery, with higher risk of complications. Future prospective studies should focus on the societal costs and patient reported outcomes, in order to do cost-benefit analysis and further evaluate the exact value of RAH in the current healthcare setting.

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