1. a) T b) T c) T d) F e) T

Studies have repeatedly shown that return to normal activities is quicker, there is less febrile morbidity, less analgesic requirements and overall reduced cost savings mainly due to reduced hospital stay with VH vs AH. It would seem sensible that DVT is less likely in view of quicker mobilization and lesser hospital stay but the data is not present to back this up.

2. a) F b) F c) T d) F e) F

Nulliparity and previous pelvic surgery can make the vaginal route more technically demanding but are not absolute contraindications. No uterine descent during examination under anaesthesia should prompt the question “why?” and is an absolute contraindication. Large uteri can be safely removed vaginally in experienced hands with the aid of morcellation and bisection. Though the abdominal route is the general rule for the surgical management of endometrial cancer the vaginal route may occasionally be appropriate in elderly less fit surgical candidates where cessation of bleeding rather than formal staging is the aim of surgery.

3. a) F b) T c) T d) T e) T

Laparoscopic surgery is particularly useful for the removal of ovaries which can sometimes be very difficult at vaginal surgery and also to assess the pelvis when there are concerns about pelvic adhesions/distorted anatomy. Vaginal hysterectomy has indeed been shown to be associated with less bladder and ureter trauma, take less time to complete, and is more economical than laparoscopic hysterectomy. Hospital stay and postoperative recovery period have also been shown to be similar for vaginal hysterectomy and laparoscopic hysterectomy.

4. a) F b) F c) F d) T e) T

There is no convincing data that STAH results in less chance of vault prolapse, improves sex life or maintains better lubrication than TAH. It has been shown to result in less urinary tract injury and on average take less time than TAH however.

5. a) F b) F c) F d) T e) T

There is no evidence to suggest any difference. Both procedures decrease dyspareunia. Most studies have shown no difference in rates of incontinence, but in one study total abdominal hysterectomy was associated with greater postoperative improvement in incontinence. Risks of stump carcinoma are comparable and very low. On the basis of best available evidence there is no difference. STAH was indeed the first hysterectomy carried out by Charles Clay of Manchester, in 1863.

6. a) T b) F c) T d) T e) T

Access is better as the uterus is rotated into the vagina, meaning access to the uterine pedicles is usually superior. The uterine fundus must be small enough to fit through the anterior colpotomy incision. Practically speaking, the uterus should be less than a 12–14 week pregnancy. Anterior colpotomy is a prerequisite to vaginal hysterectomy. Haematuria present after the procedure may indicate bladder injury.

7. a) T b) F c) T d) T e) T

Direct manual access to the myometrium allows the intraoperative location of smaller intramural fibroids. Rotation of the uterus through either a posterior or especially anterior colpotomy is difficult. Direct manual contact with the uterus and the use of conventional instruments allows for a most likely better repair. Both operating time and blood loss are roughly the same as with abdominal myomectomy. Operating time and morphine consumption are less, but hospital stay is similar.

8. a) T b) F c) F d) F e) F

Pelvic hernias are permitted to develop because of the dependent location of the urogenital hiatus in relation to the abdominal cavity as this pathway is large enough to accommodate the passage of a term infant as opposed to other herniae that occur through small defects. All the other comments can be seen in many different types of prolapse.

9. a) T b) T c) T d) T e) T

All of the above comments are true in relation to difficulty generating data on pelvic organ prolapse surgery.

10. a) T b) F c) T d) F e) T

Urinary, bowel and sexual function are in many ways the most important outcome measures of surgical success. Anatomical restoration is also important as this often correlates to symptom improvement and cost-effectiveness always comes into the equation regarding surgical success.

11. a) T b) T c) T d) T e) F

A large number of allografts, xenografts, autografts, and various synthetic implants have been proposed and used successfully as bolsters for POP surgery.

12. a) T b) F c) F d) F e) F

In 1988, the International Federation of Gynecology and Obstetrics (FIGO) formally adopted surgical staging for endometrial adenocarcinoma, including peritoneal cytology and lymph node sampling of the pelvic and peri-aortic lymph nodes. Therefore the standard treatment for endometrial carcinoma is extra-fascial hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node removal. Aortic lymphadenectomy is performed in selected patients based on pathology risk factors such as myometrial invasion, histology type and grading.

13. a) T b) T c) T d) F e) F

There are three groups of patients with endometrial cancer in whom vaginal hysterectomy is an appropriate alternative technique: patients with coexisting morbidities at high surgical risk, those with vaginal prolapse requiring vaginoplasty, and those at no risk for nodal metastases. Endometrial cancer–bearing patients frequently have coexisting morbidities, including severe obesity, diabetes mellitus, and cardiovascular diseases, increasing the risk of postoperative complications and mortality. Moreover, the prevalence of coexisting morbidities rises with age. A second group of patients are those with endometrial cancer in association with utero-vaginal prolapse, in whom the vaginal approach is preferable to perform vaginal repairs following the hysterectomy. There is a third group of patients with endometrial cancer who are at no risk for lymph node metastases and in whom hysterectomy alone is curative. Mariani et al identified a group of patients with endometrial cancer who underwent pelvic and aortic lymphadenectomy and had negative nodes. These are patients who were considered to have no risk for nodal metastases. They all had tumors of 2 cm or less in size, grade 1 or 2, with inner third myometrial invasion, no lymphatic invasion and no lower uterine segment involvement. Their 5-year survival rate was 100%. The fourth group of patients needs a different surgical approach than simple vaginal hysterectomy. In the case there is no contraindication to surgery the appropriate treatment includes radical hysterectomy, bilateral salpingo-oophorectomy and pelvic peri-aortic lymph nodes removal. However in the case the patients are not fit for surgery radical radiation treatment can be an adequate option.

14. a) F b) T c) F d) F e) T

Unfortunately, the use of vaginal hysterectomy for endometrial cancer is not very common. Maggino et al published an analysis of approaches to the treatment of endometrial cancer in leading centers of referral for gynecological cancer in Western Europe. When questioned about the vaginal approach 62.2% responded it was appropriate in selected patients with specific clinical conditions. The same authors published a similar analysis of the approaches to the treatment of endometrial cancer in leading centers of referral in North America. In regards to the indications for vaginal hysterectomy 93.7% recognized it may be utilized for specific clinical conditions such as poor performance status, obesity, concomitant pathology, prolapse and advanced age.

15. a) T b) F c) T d) T e) F

Many studies have shown that sentinel-node mapping by laparoscopy is feasible and adequate in cervical cancer. So far no studies have shown that it is safe to omit complete lymphadenectomy after a negative sentinel lymph node. The recommendation is, therefore, to continue to carry out a complete pelvic lymphadenectomy. When a positive pelvic node is found, it is indicated to carry out a para-aortic node dissection to rule out metastases and to better plan radiation therapy. Ultra staging of the sentinel nodes is the main advantage of the technique. Micro-metastases have been found in up to 30% when the frozen section was negative. Studies have shown that up to 10% of the sentinel nodes are found above the bifurcation of the iliac vessels. So sentinel-node mapping helps finding aberrant lymphatic drainage of a cervical cancer.

16. a) T b) T c) T d) F e) F

The size of the vaginal cuff depends on the size of the cervical lesions. If the lesion is 2 cm and less, the removal of only 1 cm of vaginal mucosa is enough. Contrary to the abdominal approach where the surgeon pulls the uterus upwards and therefore pulls the uterine artery up above the ureter (‘water runs under the bridge’), in vaginal surgery, the uterus is pulled downwards, so the uterine artery is also pulled down. As a result, the uterine artery becomes located under the ureter, and not above as it does in abdominal surgery. The ureter is palpated after the opening of the para-vesical space, laterally. It is important to ‘feel’ the ureter between two fingers (one in each space), or between an instrument and a finger to confirm that the space has been created correctly and the ureter will be dissected safely.

17. a) F b) T c) T d) F e) F

Only two studies have shown a significant difference. In the other studies, most of the intra-operative complications occurred at the beginning of the learning curve. Less blood loss and transfusions are a constant finding in the studies reporting results of LAVRH and total laparoscopic radical hysterectomy. As the abdomen is not open and the bowel not irritated by towels, the hospital stay is shorter in LAVRH than total laparoscopic radical hysterectomy. Abdominal radical hysterectomy has a shorter operating time. Again, when laparoscopic and vaginal surgeons gain experience, operating time becomes similar to the abdominal approach. So far, recurrence rate seems to be equivalent between the different techniques when lesions are small. Data are insufficient on lesions larger than 2 cm to be able to make any solid statements on the recurrence rates of the laparoscopic and vaginal approaches.

18. a) F b) F c) T d) T e) F

Staging of cervix cancer has remained clinical (i.e. non-surgical) and imaging is optional.

19. a) T b) T c) T d) T e) F

Risk of recurrence increases with size of tumour and presence of lymphovascular invasion. Adenocarcinomas and squamous cell carcinomas have the same survival.

20. a) F b) F c) T d) F e) T

Most women will conceive on their own. No evidence exists on restrictions during pregnancy. Caesarean section is necessary because of permanent cerclage, which is not possible to remove. The short cervix void of mucus increases the risk of premature rupture of membranes.

21. a) T b) F c) F d) T e) T

Vaginal hysterectomy is according to Cochrane review the preferred method when the surgeon is trained. It is not enough for stage IB1, which calls for radical hysterectomy but sufficient for CIN III.

22. a) T b) F c) T d) F e) T

The prevalence of SUI is known to increase with age. SUI is known to occur in women of all age groups. It is common in pregnant women as well as young athletes participating in sports activities. Factors that increase the risk of developing SUI are obesity, heavy manual labour, chronic obstructive pulmonary disease, and smoking. Stress urinary incontinence is a non-life threatening condition. Urethral hypermobility, intrinsic sphincter deficiency, or both, are the pathophysiological mechanisms responsible for SUI.

23. a) F b) F c) T d) F e) T

Anterior colporrhaphy and Kelly’s sub-urethral plication have no place in the surgical treatment of stress urinary incontinence. Because of significant recurrence rates at even 1 and 2 years, and because of the availability of minimally invasive mid-urethral sling procedures, long-needle suspension procedures such as the Pereyra, Stamey, or Raz procedures, and their other modifications, are no longer recommended.

Mid-urethral sling procedures are considered to be ‘gold standard’ operations for the treatment of stress urinary incontinence. Tension-free vaginal tape has been associated with a number of peri-operative and post-operative complications, including bowel, vascular, and bladder injuries. Studies have shown that trans-obturator tape procedure is as effective as tension free vaginal tape procedure for the treatment of stress urinary incontinence.

24. a) T b) F c) T d) T e) T

Osteoporosis is a disease of the connective tissue of the bone concerning the turnover of the extracellular matrix. Studies have shown a positive correlation with POP that has the same patho-physiological origin. On the contrary, obesity is a risk factor for prolapse and recurrence after surgery, because of increased intra-abdominal pressure. The same applies to smokers and women with obstructive broncho-pneumopathies. Family history of POP or hernia is found in 40–60% of women with POP. It is a sign of defective collagen and is a risk factor for recurrence after conventional surgery. Risk of recurrence increases with grade of prolapse because of the stronger destruction of the supportive structures and probably because of weaker collagen.

25. a) F b) T c) F d) T e) T

Certainly not. The immediate postoperative aspect may be looking better but the mucosa will be under tension. The stretching will reduce the thickness of the tissue covering the mesh. The blood supply of the mucosa around the scar will be reduced. These will all increase the erosion rate. Vaginal tissue is elastic; it resumes normal elasticity after delivery or after abdominal sacro-colpopexy within 1 week. Thus, it maintains normal thickness and vascularisation. Folds increase the thickness of the mesh and reduce pore size, enhancing the risk of shrinkage and erosion. There is no proof of efficacy of vaginal estrogens in preventing erosion. This is the right dissection plane for mesh insertion; exactly the same as for abdominal or laparoscopic sacro-colpopexy. The lightest meshes available today weigh 30–40 gram/m ² and have a pore size close to 1 mm.

26. a) T b) T c) F d) F e) T

If the woman is really asymptomatic, this is certainly only a delay in the healing process. It occurs in 2–10% of women and usually requires no treatment. Prescription for estriol tablets in post-menopausal women would seem logical. Antibiotics would be a mistake in asymptomatic women, modifying the vaginal ecosystem and leading to real infection. If the woman has symptoms of discharge or has rejected the implant (determined by checking its looseness when pulling on it), then you have to excise the rejected part (as long as the mesh has no tissue in-growth), and then close the vagina. Sometimes, the whole mesh can be removed. If erosion recurs, the whole mesh, including the trans-obturator or trans-levator arms, has to be removed.

27. a) F b) T c) T d) F e) T

Persisting pain 6 months after an operation is never a haematoma and is not likely to disappear spontaneously. It is most likely to be a neuropathy. Once a posterior sling is attached to, or passes through, the sacrospinous ligament (according to Richter’s sacrospinous ligament fixation), neuropathy of the pudendal nerve is always possible. The causes may differ but the most frequently associated causes are as follows: decompensation of a pre-existing occult neuropathy; direct entrapment of the nerve or of one of its branches by the mesh; and fibrosis induced by the graft restricting Alcock’s canal. Electromyography can show direct signs of nerve injury and dysfunction. Local infiltration with Naropin, under fingertip control or led by computed tomography scan, will significantly diminish neuropathic pain. The relief is usually only transitory but this test is necessary to prove the diagnosis of pudendal neuropathy. Anti-inflammatory drugs are absolutely inefficient in diminishing neuropathic pain. Antiepileptic (clonazepam, pregabaline) and some anti-depressive drugs (amitryptiline) have some benefit. Mesh removal is the only way to cure the pain after failure of medical treatment (pregabaline), infiltration and osteopathy. When the pain becomes chronic over time, the chances for cure diminish. Re-operation is designed to remove the piece of mesh close to the nerve and to free the pudendal nerve, usually by cutting the sacro-spinous ligament close to the ischial spine.

28. a) F b) T c) T d) T e) F

The main support for the pelvic floor is provided by the combined action of the parametrium, paracolpium and the levator ani muscle. The round ligament does not provide any significant degree of pelvic floor support. The parametrium is formed mainly of converging fibres of the uterosacral and cardinal ligament, both attached to the posterolateral aspect of the cervix to provide the main uterine support. The genital hiatus is the space within the levator muscle through which the urethra and the vagina pass, and is also called the urogenital hiatus of the levator ani. The hiatus is bound anteriorly by the pubic bone, laterally by the levator ani muscle, and posteriorly by the perineal body and external anal sphincter. It has been reported that the size of the genital hiatus correlates with the risk of developing pelvic organ prolapse. The perineal body supports the posterior aspect of the lower 3 cm of the vagina. Damage to the perineal body fibres (most commonly at the time of child birth) predisposes to the formation of a posterior wall vaginal prolapse or rectocele, caused by herniation of the anterior rectal wall through the weakened posterior vaginal wall. The uterus plays no role in increasing the risk of pelvic prolpase. It plays a passive role in the process of prolapse formation. Uterine prolapse is the result not the cause of weakening pelvic floor support leading to pelvic organ prolapse.

29. a) F b) F c) T d) T e) F

It is estimated that the life-time risk of a woman undergoing surgery for pelvic organ prolapse is 11% (one in nine). This risk is expected to rise over the next two to three decades owing to increased life expectancy and rising rates of obesity and diabetes. Both of these factors contribute to weakening of the pelvic floor support structures. Pelvic organ prolapse is more common in women with high parity. Child birth is considered to be one of the major predisposing factors for pelvic prolapse. Multiparous women have a tenfold increased risk of pelvic prolapse compared with nulliparous woman. Weakness of the pelvic floor supporting structures is the main reason behind pelvic organ prolapse. Other factors include chronic illness and raised intra-abdominal pressure. Congenital defect of collagen formation (as seen in Marfan’s or Ehlers Danlos syndromes, for example), leads to the production of abnormally weak collagen and predisposes to a number of connective tissue disorders, among which pelvic organ prolapse is a common finding. Recent anatomical understanding of the dynamics of the three levels of pelvic floor support indicates that different defects require a specific operation for its correction. Vaginal hysterectomy does not enhance the repair procedure in any way and may predispose to bladder dysfunction after surgery.

30. a) F b) F c) F d) T e) F

Vaginal pessary insertion is only used as a temporary measure in young women. It is not recommended as long-term treatment for young women because of associated dyspareunia and the risk of vaginal wall erosion from prolonged use. The evidence for the benefit of pelvic floor exercises as the sole treatment for pelvic organ prolapse is considered poor. Published research is heterogeneous and mainly composed of small studies with design shortcomings and poor reporting of outcome measures. Hysterectomy provides no or little benefit for the treatment of utero-vaginal prolapse in young women. In addition to negative body image, hysterectomy is not a surgical option for women who desire further childbearing. Posterior colporrhaphy is associated with up to 20% risk of dyspareunia in young women because of resulting vaginal narrowing, shortening and scarring in the levator ani muscle. An extra-peritoneal approach is totally used for sacrospinous ligament fixation, thus posing no risk of tubal damage or formation of intra-peritoneal pelvic adhesions.