BACKGROUND: There is a scarcity of prospective clinical research evidence regarding the utilization of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) as a treatment option for ovarian cysts. The objective of this study was to assess the feasibility and safety of employing vNOTES for the management of ovarian cysts.
METHODS: Our study included women between the ages of 18 and 70 who intended to undergo surgical intervention for benign lesions. Stratified blocked randomization was employed to allocate participants into groups. The main objective was to assess whether the assigned group adhered to the recommended surgical technique for ovarian cystectomy or adnexectomy, without any deviation to alternative surgical methods.
RESULTS: A total of 196 patients were included in the study, with all surgeries in each group being conducted according to the assigned procedures. Among them, the ovarian cystectomy layer included 58 cases in the vNOTES group and 58 cases in the conventional laparoscopy (CL) groups. The adnexectomy layer included 40 cases in the vNOTES group and 40 cases in the CL group. Utilizing a sensitivity analysis, the two-sided 95% lower confidence limit was determined to be 5.5% for the disparity in proportions between the vNOTES groups and CL groups. These lower limits fell below the predetermined non-inferiority margin of 10%.
CONCLUSIONS: The study findings demonstrate that vNOTES was not inferior to CL in terms of adnexectomy or ovarian cystectomy. vNOTES can be considered a more minimally invasive surgical approach, as it results in reduced postoperative pain, faster recovery, and absence of visible incisions. Overall, vNOTES proves to be a safe, feasible, and less invasive treatment option.
BACKGROUND: This study retrospectively registered with the China Clinical Trial Registry with the registration number ChiCTR2100052223(22-10-2021).

OBJECTIVE: The primary aim was the validation of benign descriptors (BDs), followed by Assessment of Different NEoplasia\'s of the adneXa (ADNEX) (when BDs cannot be applied), in a two-step strategy to classify adnexal masses in pregnancy. The secondary aim was to describe the natural history of adnexal masses in pregnancy.
METHODS: Retrospective analysis of prospectively collected data of women with an adnexal mass on ultrasonography identified during pregnancy between 2017 and 2022. The study was conducted at Queen Charlotte\'s and Chelsea Hospital, UK. Relevant clinical and ultrasound data were extracted from the medical records and ultrasound software astraia. Adnexal masses were classified and managed according to expert subjective assessment (SA). Ultrasound features were recorded prospectively at the time of ultrasound examination. Borderline ovarian tumours (BOT) were classified as malignant. Benign Descriptors (BDs) were applied to classify adnexal masses, in cases where BDs were not applicable, the ADNEX model (using a risk of malignancy of >10%) was used, in a two-step strategy. The two-step strategy was applied retrospectively. The reference standard used was histology (where available) or expert SA at the postnatal ultrasound scan.
RESULTS: 291 women with a median age of 33 (IQR 29-36) years presented with an adnexal mass in pregnancy, at a median gestation of 12 (IQR 8-17) weeks. 267 (267/291, 91.8%) women were followed up to the postnatal period, as 24 women (24/291, 8.2%) were lost to follow up. Based on the reference standard, 4.1% of adnexal masses (11/267) were classified as malignant (all BOTs) and 95.9% (256/267) as benign (41 on histology and 215 based on expert SA at postnatal ultrasound). BDs could be applied to 68.9% of adnexal masses (184/267); of these only one mass (BOT) was misclassified as benign (1/184, 0.5%). ADNEX was used to classify the residual masses (83/267) and misclassified three BOTs as benign (3/10, 30.0%) and 25 benign masses (based on reference standard) as malignant (25/73, 34.2%), 13 (13/25, 52.0%) of these were classified as decidualised endometriomas on expert SA, with confirmed resolution of decidualisation in the postnatal period. The two-step strategy had a specificity of 90.2%, sensitivity of 63.6%, negative predictive value of 98.3% and positive predictive value of 21.9%. 56 (56/267, 21.0%) women had surgical intervention, four as an emergency during pregnancy (4/267, 1.5%,) and four (4/267, 1.5%) electively during caesarean section. 48 (48/267, 18.0%) women had surgical intervention in the post-natal period, 11 (11/267, 4.1%) in the first 12 weeks postnatal and 37 >12 weeks (37/267, 13.9%) postnatal. 64 (64/267, 24.0%) adnexal masses resolved spontaneously during follow up. Cyst-related complications occurred in four women (4/267, 1.5%) during pregnancy (ovarian torsion n=2, cyst rupture n=2) and six (6/267, 2.2%) in the postnatal period (all ovarian torsion). 196 (196/267, 73.4%) had a persistent adnexal mass, including one of the women who had an ovarian torsion and underwent de-torsion and had a persistent adnexal mass at postnatal ultrasound. Presumed decidualisation occurred in 31.1% (19/61) of endometriomas and had resolved in 89.5% (17/19) by the first postnatal ultrasound scan.
CONCLUSIONS: We found Benign Descriptors apply to most masses in pregnancy, however the small number of malignant tumours in the cohort (4.1%) restricted the evaluation of the ADNEX model, so expert subjective assessment should be used to classify adnexal masses in pregnancy, when BDs do not apply. A larger multicentre prospective study is required to evaluate the use of the ADNEX model to classify adnexal masses in pregnancy. Our data suggests that most adnexal masses can be managed expectantly during pregnancy given a large proportion of masses spontaneously resolved and the low risk of complications. This article is protected by copyright. All rights reserved.

BACKGROUND: Spinal anesthesia offers numerous advantages and desirable features. However, it is associated with various side effects related to local anesthetic agents used. Reducing the dose of local anesthetic in spinal anesthesia can help minimize side effects but may lead to a diminished analgesic effect or failure of anesthesia. Therefore, adding an adjuvant may enhance the benefits while mitigating side effects.
OBJECTIVE: This study aimed to evaluate the effects of ketamine and tramadol as adjuvants to bupivacaine on the duration of spinal analgesia. The objectives were to compare the three groups and prove their analgesic effects, safety, and superiority. The primary outcomes were the duration of spinal analgesia, as well as the onset and duration of both sensory and motor blocks. Secondary outcomes included the heart rate, mean arterial pressure, and the incidence of undesired effects such as nausea, vomiting, sedation, shivering, and postoperative headache.
METHODS: In this double-blind randomized controlled trial, 120 female patients undergoing elective open unilateral ovarian cystectomy under spinal anesthesia were studied. The inclusion criteria included patients aged 16-45 years with a physical status classified as American Society of Anesthesiologists (ASA) class I and II. Patients were randomly allocated into three groups: group B (n=40) received only bupivacaine, group BK (n=40) received bupivacaine mixed with preservative-free ketamine, and group BT (n=40) received bupivacaine mixed with preservative-free tramadol.
RESULTS: The mean duration of spinal analgesia, measured in minutes, showed significant differences (P < 0.001) between group BK (165 ± 4) and group B (170 ± 5). There was also a significant difference between group BT (313 ± 8) and group B (170 ± 5) (P < 0.001). Additionally, significant differences were observed between group BK (165 ± 4) and group BT (313 ± 8) (P < 0.001).
CONCLUSIONS: The administration of 25 mg of ketamine and 25 mg of tramadol as adjuvants to bupivacaine in spinal anesthesia significantly affected the postoperative duration of analgesia. Tramadol prolonged the duration of spinal anesthesia, while ketamine shortened it. The use of both adjuvants did not result in undesired effects.

Increasing observational studies have indicated that hormonal reproductive factors were associated with ovarian cyst, a common gynecological disease. A two-sample Mendelian randomization (MR) was carried out by investigating the causality of reproductive factors including age at first birth (AFB), age at natural menopause (ANM), and age at menarche (AAM), and the risk of ovarian cyst (OC).
Summary statistics were collected from a large genome-wide association study (GWAS), and we used a two-sample MR study to clarify the causal association between the exposure of AFB (N = 542,901), ANM (N = 69,360), and AAM (N = 29,346) and the outcome of the OC (N case = 20,750, N control = 107,564). We separately selected 51, 35, and 6 single-nucleotide polymorphisms (SNPs) as instrumental variables (IVs) for assaying the influence of AFB, ANM, and AAM on OC, respectively. Then, the causal relationship was tested through multiple approaches including an inverse-variance weighted method, an MR-Egger regression, and a weighted median method. In addition, the MR-PRESSO method was also used to verify the horizontal pleiotropy. Subsequently, we adjust the confounders for MR design.
The MR analysis results showed that AFB was negatively associated with the OC (IVW Beta: -0.09, OR: 0.91, 95% CI: 0.86-0.96, p = 0.00185), and the greater AAM decreased the risk of OC (IVW Beta: -0.10, OR: 0.91, 95% CI: 0.82-0.99, p = 0.0376). However, ANM has a positive correlation with the OC (IVW Beta: 0.05, OR: 1.05, 95% CI: 1.03-1.08, p = 8.38 × 10-6). After adjusting BMI, alcohol intake frequency, and ever smoked, we also obtained a negative relationship between AFB and OC (p < 0.005). Meanwhile, we adjusted weight, alcohol intake frequency, and height, and then found a causal relationship between older AMN and an increased risk of OC (p < 0.005).
A causal effect of reproductive factors on the development of OC, affected by AFB, ANM, and AAM, was found convincingly. After adjusting the confounders, we also successfully found the substantial causal effect of younger AFB, younger AAM, and older ANM on an increased risk of OC.

UNASSIGNED: Explore the causal relationship between the ovarian cyst and depression using a two-sample Mendelian randomization approach (MR).
UNASSIGNED: Based on data pooled from genome-wide association studies, genetic variants of the ovarian cyst and depression were selected as instrumental variables, as well as the Mendelian randomization analysis was conducted using inverse variance weighted (IVW) as the main analysis method and MR-Egger regression analysis, MR-PRESSO and other sensitivity analysis methods as supplements.
UNASSIGNED: The IVW analysis showed a direct causal association between ovarian cysts and depression (OR=1.040; 95% CI: 1.003, 1.078; p=0.031). Meantime, there was a causal effect of genetically predicted depression on ovarian cysts (OR=1.327.; 95% CI: 1.197, 1.470; p<0.001). Sensitivity analyses such as MR-Egger regression analysis and MR-PRESSO indicated that the IVW results were robust and reliable.
UNASSIGNED: This study suggested since ovarian cysts and female depression are mutually causal, the comorbidity of ovarian cysts and depression in women should be actively attended to and given appropriate prevention and treatment besides the diagnosis and treatment of depression or ovarian cysts.

Discover the rate of post-operative constipation in participants undergoing elective laparoscopy for benign gynecological indications DESIGN: Prospective observational study SETTING: Single site, tertiary level gynecology unit with a focus on pelvic pain and endometriosis.
Recruited participants were patients of the institution over the age of 18 who had planned to undergo an elective laparoscopy for benign gynecological indications prior to enrolment in the study. Participants were excluded if they were not English speaking, had a chronic bowel condition (with the exception of irritable bowel syndrome), were planned to have bowel surgery, hysterectomy, or converted to laparotomy.
In this prospective study, participants completed 3 consecutive surveys. One prior to surgery, one a week post-surgery, and a third 3 months post-surgery. The surveys collected data regarding the participant\'s bowel habits, pain relief used, laxatives used, and the distress or bother caused by their bowels.
Constipation was defined by a modified ROME IV criteria. Opiate use and laxative use were defined by patient-reported tablet counts. The level of distress was measured as a continuously variable scale from 0 to 100. Variables adjusted for included subject\'s demographics, pre-operative constipation, indication for surgery, duration of surgery, estimated blood loss, opiate use (preoperative, peri-operative, and post-operative), laxative use, and length of stay. A total of 153 participants were recruited, of which 103 completed both the pre-operative and post-operative survey. Post-operative constipation was present in 70% of participants. The mean length of time to first bowel motion was 3 days, with 32% of participants having their first bowel motion after the third post-operative day. The level of bother caused by their bowel habit was higher in the constipation group compared to those without constipation. Post-operatively opiates were used in 84.9% of participants, and laxatives were used in 47.1%. Visits to the general practitioner for constipation occurred in 5.8% of participants.
Post-operative constipation is common and bothersome in participants who undergo elective laparoscopy for benign gynecological indications. Analysis of individual variables failed to identify any factors that influenced the rate of constipation.

Uterine leiomyoma should be considered when a female patient reports symptoms of abdominal pressure and abnormal vaginal bleeding. However, the symptoms of a uterine leiomyoma are vast and overlap with other possible diseases that are difficult to distinguish even with imaging studies. This is why it is important for physicians and healthcare providers to keep an open mind and have a broad differential diagnosis.  In this case study, we present a 61-year-old postmenopausal female patient who presented to the emergency department with complaints of pelvic and abdominal pain, as well as vomiting and diarrhea. She was admitted for observation. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis revealed no abnormalities; a pelvic ultrasound and CT scan reported possible adnexal torsion. The patient remained stable and the pain had subsided when she was seen the next morning by her gynecologist (GYN) who discharged her to follow-up in the office. Subsequent examinations that aided in the diagnosis included, but were not limited to pelvic and transvaginal ultrasounds, an abdominal and pelvic CT, and a pelvic MRI. In this case, the MRI revealed an 11-cm mass that could represent a torsioned pedunculated necrotic fibroid originating from the uterus. Radiology recommended surgical removal. Upon removal and review of the pathology of the mass, it was revealed to be a torsioned, partially necrotic fibroma that had originated from the ovary and not from the uterus, as imaging had originally suggested.

OBJECTIVE: Adnexal torsion remains a diagnostic challenge due to the nonspecific symptoms, sonographic features, and laboratory findings. The value of combining clinical, sonographic, and laboratory features is not well established, and controversy continues regarding their value in diagnosis. This study aimed to review sonographic, clinical, and laboratory features and to analyze their value separately and in combination, in managing and diagnosing adnexal torsions.
METHODS: The study included 278 women who underwent urgent laparoscopic surgery due to suspected adnexal torsion, according to clinical suspicion, with or without sonographic concordance. Laparoscopy findings confirmed the definitive diagnosis of torsion. Clinical laboratory and sonographic features were compared between those with and without adnexal torsion.
RESULTS: Adnexal torsion was confirmed in 110/278 (39.6%) women. In the torsion compared to nontorsion group, proportions were higher of women with acute abdominal pain in the preceding 24 h ([50] 45.5% vs. [35] 20.8%, p < 0.001), with vomiting ([45] 40.9% vs. [24] 14.3%, p < 0.001) and with suspected torsion by transvaginal sonography ([49] 44.5% vs. [23] 13.7%, p < 0.001). A high neutrophil-to-lymphocyte ratio (>3) was identified in 65 (59.1%) of the study group and 60 (35.7%) of the control group (p < 0.001). Combining the latter three findings, the predicted probability of torsion was 58%-85%, depending on the combinations.
CONCLUSIONS: A simple predictive model based on combinations of clinical, laboratory, and sonographic findings can contribute to preoperative diagnosis of adnexal torsion, with predicted probability of 85%. Our model may assist clinicians in evaluating women with suspected adnexal torsion, and improve preoperative diagnostic accuracy.

UNASSIGNED: The incidence of ovarian cystic lesions (OCLs) in pediatric patients has been increasing in recent years. An early diagnosis is mandatory for a favourable prognosis but it depends on the primary medical care services and on the socioeconomic status of the patient. The present study aims at assessing the prevalence and the age-specific frequencies of pediatric OCLs, as well as identifying disparities between subjects in the urban and the rural areas, in order to explore the extent to which OCLs occurrence, diagnosis, evolution and treatment differ in the case of patients living in rural areas.
UNASSIGNED: A 3-year retrospective study was conducted between 2017 and 2019. All the female patients aged between 0 and 18 with OCLs ≥10 mm (N = 488), diagnosed and treated at \"Sf.Ioan\" Clinical Emergency Hospital for Children in Galaţi were included in the study. The Chi2 test was used for comparing the distributions of frequencies, and the t-Student test was used for comparing the means of any two normally distributed variables. The statistical significance threshold (p) was set at 0.05.
UNASSIGNED: The prevalence of OCLs ≥10 mm was 14.85%, 47.13% of the subjects originating in rural area (p = 0.62). Different from the urban areas, the rural ones are characterised by a lower proportion of patients with BMI ≥25 (p = 0.002), larger OCLs mean size (p = 0.278), a more frequent complex aspect on ultrasonography (p = 0.01), and a smaller number of general physician referrals (p = 0.005). Moreover, a higher proportion of rural patients were intraoperatively diagnosed with OCLs (p = 0.044), had complicated OCLs (p = 0.012) and had their OCLs surgically treated OCLs (p < 0.01).
UNASSIGNED: Taking into consideration the socio-economic situation of south eastern Romania, patients living in rural areas have proven exposed to a higher risk of presenting with larger, complex and complicated OCLs, which most often require surgical treatment.

UNASSIGNED: Ovarian cyst is an emerging problem among the women of reproductive age group. Most of the ovarian cyst (80%-85%) are benign, and two-thirds of these occur in women between 20 and 44 years of age. They may be identified in asymptomatic women during routine pelvic examination or may produce symptoms. Management of the ovarian cyst through surgery is available to meet urgent need of the patient, but to establish a satisfactory conservatory medical treatment is the need of the hour. According to Ayurveda, ovarian cysts can be managed on the line of Kaphaja Granthi (nodular/glandular swellings by Kapha Dosha) and Vidradhi (abscess).
UNASSIGNED: The aim of this study was to evaluate the clinical efficacy of Virechana (therapeutic purgation), Triphaladi Kashaya (decoction) with processed Guggulu (Commiphora mukul Engl.) in the management of ovarian cyst.
UNASSIGNED: 16 patients were included in this clinical study and among them, 15 patients completed the treatment and one patient was dropped out from the trial. Patients were given Virechana followed by Triphaladi Kashaya (50 ml) with processed Guggulu (1 g) orally twice a day before meal for 60 days. The patients were followed up till 1 month. The assessment was carried out on subjective parameters such as lower abdominal pain, backache, and dysmenorrhea as well as objective parameters such as ovarian cyst size and volume by four-dimensional gray scale and color doppler sonography. Cancer antigen 125 was also assessed before and after treatment. Results were statistically analyzed using Wilcoxon signed-rank test and Student\'s t-test by sigma statistical tool (version 3.5, Systat Software Inc., United States).
UNASSIGNED: Significant results were observed in subjective parameters such as lower abdominal pain (93.11%), backache (81.81) and dysmenorrhea (90.90%) as well as objective parameters such as reduction in size of the cyst (60%) and complete resolution of the cyst (26.66%).
UNASSIGNED: Triphaladi Kashaya with processed Guggulu is more effective in hemorrhagic cyst and simple cyst rather than other cyst, due to Shothahara properties which may have effectively curtailed the progress of ovarian cyst.