We thank each participant and staff for their assistance in this study. Special thanks to Hong L for her assistance in figure editing.

The Institutional Review Board of the hospital approved the protocol (IRB Approval Number 2021-040). Informed consent for publication was obtained from each participant. Inclusion criteria encompassed women diagnosed with uterine prolapse at Pelvic Organ Prolapse Quantification (POP-Q) stage 2 or higher with related symptoms who were eligible for surgical treatments and were able to read Chinese. Assessment for eligibility was performed by a gynecologist at the hospital. All patients had a standardized preoperative POP assessment using the POP-Q system in the lithotomy position as well as via ultrasonography. Patients with co-existing anterior/posterior defects or concomitant incontinence surgery were also included. Women with contraindications for laparoscopic surgery, established genital malignancy, previous surgical treatment of vault prolapse, language issues and those not available for follow-up were excluded. Patients agreed to return the questionnaires and visit the follow-up appointments. See Table of Materials for details about equipment and other materials used in this protocol.
1. Planning for prolapse surgery
<ol>
	<li>Inform the patients about the risks and potential complications, including the possibility of switching to open laparotomy, excessive bleeding, wound infection, and postoperative recurrence.</li>
	<li>After obtaining informed consent, administer enoxaparin sodium injection (100 AXaIU/kg) for perioperative thrombosis prophylaxis.</li>
	<li>Have an anesthesiologist administer endotracheal general anesthesia and monitor vital signs. Administer perioperative prophylactic antibiotics intravenously 30 min before surgery; use cefuroxime (1.5 g) unless there is an allergic history.</li>
	<li>Following field skin disinfection, establish pneumoperitoneum using the Veress needle technique for insufflation via the umbilicus9.
	<ol>
		<li>Place a 10 mm trocar via the umbilicus for an optical device, and introduce three 5 mm trocars (see Table of Materials) under direct visualization in the lower abdomen.</li>
		<li>Maintain gas intake flow at 20 L/min, and intraperitoneal pressure at 12 mmHg.</li>
	</ol>
	</li>
</ol>
2. Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation (LNMCPUP) approach
<ol>
	<li>Perform laparoscopic bilateral salpingo-oophorectomy in postmenopausal patients. Electrocoagulate and sever the round ligament (Figure 1), attaching it to the cervical isthmus.</li>
	<li>Open the vesico-uterine recursion peritoneum to expose the uterine artery.</li>
	<li>Expose&#160;the iliopectineal ligament near the landmarks-the round ligament and the obliterated umbilical artery-make an incision in the peritoneum and detach the surrounding soft tissue between the lateral umbilical ligament and round ligament, below which the iliopectineal ligament is located. Avoid contact with the external iliac vessel and obturator nerve in the target surgical region.</li>
	<li>To perform cervico-isthmic cerclage, start at 4 o&#39;clock on the right side and go counterclockwise (Figure 2A), use a permanent suture (size 2, see Table of Materials) in the uterine isthmus to suture, ligate, and attach a round ligament to the cervical isthmus. Complete one round until the starting point is reached, performing peripheral movements with the needle around the cervix (Figure 2B). Tighten and secure the stitch after completing the cervical cerclage (Figure 2C).</li>
	<li>Embed the permanent suture into the round ligament, ending at the iliopectineal ligament (Figure 3A,B).</li>
	<li>Insert the stitch through the iliopectineal ligament (Figure 4A,B), and ensure suspension without tension (Figure 5).</li>
	<li>Repeat steps 2.1-2.6 on the other side of the pelvis.</li>
	<li>Perform peritoneal closure with an absorbable synthetic polyglactin braided suture (size 2-0, see Table of Materials).</li>
	<li>Perform anterior and/or posterior colporrhaphy if patients suffering from symptomatic POP &#8805; stage 2 including anterior and/or posterior vaginal wall defect. Separate the vaginal wall from cervix and pouch sutured for 1 to 2 rounds in the outer bladder/rectal fascia to repair the cystocele/rectocele.Suture arcus tendinous fascia pelvis/arcus tendinous musculi levator ani in a U-shape and closed anterior and/or posterior vagina wall.</li>
	<li>Perform anti-incontinence surgery inside-out tension-free vaginal tape-obturator (TVT-O) before LNMCPUP if patients are diagnosed with serious Stress Urinary Incontinence (SUI) based on preoperative urodynamic examination. If patients were diagnosed with middle SUI, counsel them about the risk of postoperative SUI condition aggravation, and perform TVT-O at the patients&#39; discretion. 
	NOTE: The LNMCPUP technique is shown in a schematic diagram (Figure 6).</li>
</ol>
3. Management after LNMCPUP surgery
<ol>
	<li>Record necessary data, including the operation time of LNMCPUP, total blood loss, and associated complications.</li>
	<li>Advise all postmenopausal patients to use low-dose transvaginal estrogen for 6 weeks after surgery.</li>
	<li>Advise all patients to engage in pelvic floor exercises starting 8 weeks after surgery.</li>
	<li>Perform follow-up of patients 6 weeks, 6 months, and 1 year after surgery.
	<ol>
		<li>Conduct a gynecological examination using POP-Q system for assessing prolapse, an important reference point is the hymen.Grade genital prolapse stages 1-4 according to achieved optimal POP-Q scores.</li>
		<li>Ask patients to complete Patient Global Impression of Improvement (PGI) questionnaire to evaluate the postoperative condition relative to the condition before the surgical intervention. Use a single question to rate the condition; the answer will be on a scale from &#34;1. Very much better&#34; to &#34;7. Very much worse&#34;10.</li>
		<li>Ask the patients to complete the Prolapse Quality of Life (P-QOL) questionnaire and the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ-12). 
		NOTE: The PISQ-12 is a self-administered questionnaire that evaluates the sexual function of women with pelvic organ prolapse or urinary incontinence11.</li>
	</ol>
	</li>
	<li>Calculate the subjective and objective success rates. Define objective success as the absence of prolapse of the vault beyond the hymen, with optimal POP-Q stage &#8804;1. Define subjective success as the absence of bothersome bulge symptoms (vaginal bulging and protrusion according to the validated questionnaire), without repeat surgery or pessary use for recurrent vault prolapse12. 
	NOTE: We considered an objective success rate of our medical care if POP-Q measurements Ba, Bp, and C &#8804; 0 (optimal POP-Q stage &#8804; 1) and a subjective success rate of our medical care if the PGI was&#8804; 2. Systematic assessment was done for complications such as de novo SUI, reoperation for SUI or recurrent POP, and de novo dyspareunia.</li>
</ol>

Uterine-Preserving Laparoscopic Cerclage Pectopexy 

<ol>
	<li>Subak, L. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cost+of+pelvic+organ+prolapse+surgery+in+the+United+States.">Cost of pelvic organ prolapse surgery in the United States.</a> Obstet Gynecol. 98 (4), 646-651 (2001).</li><li>Seisen, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Results+obtained+after+robotic-assisted+laparoscopic+sacral+colpopexy+for+the+management+of+urogenital+prolapse:+a+review.">Results obtained after robotic-assisted laparoscopic sacral colpopexy for the management of urogenital prolapse: a review.</a> Prog Urol. 22 (3), 146-153 (2012).</li><li>Maher, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgery+for+women+with+apical+vaginal+prolapse.">Surgery for women with apical vaginal prolapse.</a> Cochrane Database Syst Rev. 10 (10), CD012376 (2016).</li><li>No&#233;, K. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pectopexy:+a+prospective,+randomized,+comparative+clinical+trial+of+standard+laparoscopic+sacral+colpocervicopexy+with+the+new+laparoscopic+pectopexy-postoperative+results+and+intermediate-term+follow-up+in+a+pilot+study.">Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study.</a> J Endourol. 29 (2), 210-215 (2015).</li><li>Maher, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgery+for+women+with+apical+vaginal+prolapse.">Surgery for women with apical vaginal prolapse.</a> Cochrane Database Syst. Rev. 7 (7), CD012376 (2023).</li><li>Zhang, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+non-mesh+cerclage+pectopexy+for+pelvic+organ+prolapse.">Laparoscopic non-mesh cerclage pectopexy for pelvic organ prolapse.</a> J Vis Exp. (187), e64388 (2022).</li><li>Korbly, N. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patient+preferences+for+uterine+preservation+and+hysterectomy+in+women+with+pelvic+organ+prolapse.">Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse.</a> Am J Obstet Gynecol. 209 (5), 470.e1-470.e6 (2013).</li><li>Meriwether, K. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Uterine+preservation+vs+hysterectomy+in+pelvic+organ+prolapse+surgery:+a+systematic+review+with+meta-analysis+and+clinical+practice+guidelines.">Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines.</a> Am J Obstet Gynecol. 219 (2), 129-146.e2 (2018).</li><li>Zeng, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Introduction+of+intracapsular+rotary-cut+procedures+(IRCP):+A+modified+hysteromyomectomy+procedures+facilitating+fertility+preservation.">Introduction of intracapsular rotary-cut procedures (IRCP): A modified hysteromyomectomy procedures facilitating fertility preservation.</a> J Vis Exp. (143), e58410 (2019).</li><li>Srikrishna, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validation+of+the+Patient+Global+Impression+of+Improvement+(PGI-I)+for+urogenital+prolapse.">Validation of the Patient Global Impression of Improvement (PGI-I) for urogenital prolapse.</a> Int Urogynecol J. 21 (5), 523-528 (2010).</li><li>Occhino, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validation+of+a+visual+analog+scale+form+of+the+pelvic+organ+prolapse/urinary+incontinence+sexual+function+questionnaire.">Validation of a visual analog scale form of the pelvic organ prolapse/urinary incontinence sexual function questionnaire.</a> Female Pelvic Med ReconstrSurg. 17 (5), 246-248 (2011).</li><li>Barber, M. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pelvic+floor+disorders+network.+Defining+success+after+surgery+for+pelvic+organ+prolapse.">Pelvic floor disorders network. Defining success after surgery for pelvic organ prolapse.</a> Obstet Gynecol. 114 (3), 600-609 (2010).</li><li>Smith, F. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lifetime+risk+of+undergoing+surgery+for+pelvic+organ+prolapse.">Lifetime risk of undergoing surgery for pelvic organ prolapse.</a> Obstet Gynecol. 116 (5), 1096-1100 (2010).</li><li>Sarlos, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+sacrocolpopexy+for+uterine+and+post-hysterectomy+prolapse:+anatomical+results,+quality+of+life+and+perioperative+outcome-a+prospective+study+with+101+cases.">Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results, quality of life and perioperative outcome-a prospective study with 101 cases.</a> Int Urogynecol J Pelvic Floor Dysfunct. 19 (10), 1415-1422 (2008).</li><li>Banerjee, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=a+new+technique+of+prolapse+surgery+for+obese+patients.">a new technique of prolapse surgery for obese patients.</a> Arch Gynecol Obstet. 284 (3), 631-635 (2011).</li><li>Szymczak, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopic+techniques+for+apical+organ+prolapse+repair+-+a+systematic+review+of+the+literature.">Comparison of laparoscopic techniques for apical organ prolapse repair - a systematic review of the literature.</a> Neurourol Urodyn. 38 (8), 2031-2050 (2019).</li><li>Obut, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+the+quality+of+life+and+female+sexual+function+following+laparoscopic+pectopexy+and+laparoscopic+sacrohysteropexy+in+apical+prolapse+patients.">Comparison of the quality of life and female sexual function following laparoscopic pectopexy and laparoscopic sacrohysteropexy in apical prolapse patients.</a> Gynecol Minim Invasive Ther. 10 (2), 96-103 (2021).</li><li>Chan, C. Y. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+of+the+surgical+management+of+apical+pelvic+organ+prolapse.">A systematic review of the surgical management of apical pelvic organ prolapse.</a> Int Urogynecol J. 34 (4), 825-841 (2023).</li><li>Anglim, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+do+patients+and+surgeons+decide+on+uterine+preservation+or+hysterectomy+in+apical+prolapse.">How do patients and surgeons decide on uterine preservation or hysterectomy in apical prolapse.</a> Int Urogynecol J. 29 (8), 1075-1079 (2018).</li><li>Kostov, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Corona+mortis,+aberrant+obturator+vessels,+accessory+obturator+vessels:+clinical+applications+in+gynecology.">Corona mortis, aberrant obturator vessels, accessory obturator vessels: clinical applications in gynecology.</a> Folia Morphol (Warsz). 80 (4), 776-785 (2021).</li></ol>

No conflicts of interest were declared by the authors.

A significant number of elderly women worldwide experience Pelvic Organ Prolapse (POP), which involves the descent of at least one pelvic organ. As society ages, the demand for POP surgery is expected to rise dramatically13. Laparoscopic Sacrocolpopexy (LS) is the primary surgical technique for addressing apical prolapse. However, the high incidence of postoperative defecation problems associated with LS cannot be overlooked14. Laparoscopic Pectopexy (LP)&#160; an alternati...

Pelvic organ prolapse (POP) significantly impacts the well-being of a substantial portion of parous women over 50 years old1. With an increasing average lifespan, a higher number of women will require POP surgery. The gold standard for treating uterine prolapse is laparoscopic sacrocolpopexy (LS), in which the vaginal apex is attached to the sacrum over the third and fourth sacral vertebrae using mesh, boasting a success rate exceeding 95% and long-term durability2. However, LS is a challenging procedure commonly associated with postoperative defecation problems3. Additionally, LS may not be suitable for obese patients. Laparoscopic pectopexy (LP), in which the iliopectineal ligaments are used for a bilateral mesh fixation of vaginal vault or cervical stump, has emerged as a viable alternative to LS for addressing apical prolapse, due to comparable clinical efficacy and a lower incidence of defecation disorders4.
However, the usage of synthetic mesh for apical support in LS and LP causes mesh-related complications, increasing patient suffering and medical expenses5. Our team has published a new procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), embedding permanent cervical cerclage sutures in the round ligament until the iliopectineal ligament. This was successfully performed with high objective and subjective success rates6. Recent evidence suggests that many women with prolapse issues desire to preserve their uterus, which is paramount for maintaining self-confidence, self-esteem, and a sense of femininity7.
The current research reports the development of a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for POP (LNMCPUP) for addressing apical prolapse. This novel technique involves embedding cervical cerclage sutures in the round ligament until the iliopectineal ligament, resulting in a firm uterine suspension. In addition, without using synthetic mesh, this procedure obviates mesh erosion while reducing medical costs. Moreover, this procedure ensures that the uterus is preserved, thereby minimizing perioperative risks associated with hysterectomy and eliminating significant alterations in POP surgery outcomes8.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>5 mm trocars</td>
			<td>KARL STORZ, Germany</td>
			<td>30160X</td>
			<td>Endoscopic equipment</td>
		</tr>
		<tr>
			<td>10 mm trocars&#160;</td>
			<td>KARL STORZ, Germany</td>
			<td>30160 H2</td>
			<td>Endoscopic equipment</td>
		</tr>
		<tr>
			<td>Cefuroxime sodium for injection&#160;</td>
			<td>YOUCARE , China</td>
			<td>H20063758</td>
			<td>Prophylactic antibiotics</td>
		</tr>
		<tr>
			<td>Enoxaparin sodium for injection&#160;</td>
			<td>TECHDOW , China</td>
			<td>H20056847</td>
			<td>Perioperative thrombosis prophylaxis</td>
		</tr>
		<tr>
			<td>Ethibond size 2</td>
			<td>ETHICON, USA</td>
			<td>X519H&#160;</td>
			<td>Nonabsorbable braided polyester</td>
		</tr>
		<tr>
			<td>VICRYL 2-0</td>
			<td>ETHICON, USA</td>
			<td>VCP317H</td>
			<td>Absorbable braided suture</td>
		</tr>
	</tbody>
</table>

laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for treating POP. Recent research has increasingly validated the efficacy and safety of laparoscopic pectopexy (LP) for addressing apical POP. However, the cost of synthetic mesh and associated complications restrict the widespread use of this technique. Our team previously published a study describing a novel, non-mesh procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), demonstrating successful outcomes with satisfactory objective and subjective success rates. Many patients express a preference for retaining their uterus during prolapse surgery due to considerations related to sexuality, partnership, and body image. 
The present research introduces a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation (LNMCPUP) for POP, wherein the uterus is suspended to the iliopectineal ligament through the round ligament using permanent cerclage sutures. We successfully performed this procedure in 14 cases at our hospital, six of whom still had menstruation, and the remaining eight were postmenopausal, with a mean operation time of 54.43 min (&plusmn; 10.18 min) and an average bleeding volume of 53.57 mL (&plusmn; 48.77 mL). The mean follow-up duration was 19.71 &plusmn; 15.87 months. The objective success rate of LNMCPUP was 100%, with a subjective success rate of 92.86%. No significant complications were observed during or after surgery. LNMCPUP integrates cervical cerclage and shortening of the round ligament, as well as LP without using mesh, thereby eliminating the risk of mesh erosion and lowering healthcare costs. Moreover, this novel technique is relatively easy to master, making it accessible even in rural and underdeveloped areas where synthetic mesh is unavailable. Therefore, it is worthwhile to adopt LNMCPUP in POP patients who desire the preservation of their uterus.

We successfully performed Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation (LNMCPUP) in 14 patients over the past 2 years, six of whom were premenopausal, and the remaining eight were postmenopausal. Their average &#177; Standard deviation (SD) age was 52.93 &#177; 9.94 years, with a mean &#177; SD Body mass index (BMI) of 23.46 &#177; 1.95. The average &#177; SD bleeding volume during surgery was 53.57 &#177; 48.77 mL, and the mean &#177; SD operation time was 54.43 &#177; 10.18 min. T...

Author Spotlight: Advancing Pelvic Prolapse Treatment with a Non-Mesh Approach using Laparoscopic Pectopexy

Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament.

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for ...

laparoscopic-non-mesh-cerclage-pectopexy-with-uterine-preservation

Research

JoVE Journal

Medicine

1.2K Views.  The University of Hong Kong-Shenzhen Hospital. Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament. 

Video: Author Spotlight: Advancing Pelvic Prolapse Treatment with a Non-Mesh Approach using Laparoscopic Pectopexy

Normothermic Ex Vivo Kidney Perfusion for the Preservation of Kidney Grafts prior to Transplantation

Kidney transplantation has become a well-established treatment option for patients with end-stage renal failure. The persisting organ shortage remains a serious problem. Therefore, the acceptance criteria for organ donors have been extended leading to the usage of marginal kidney grafts. These marginal organs tolerate cold storage poorly resulting in increased preservation injury and higher rates of delayed graft function. To overcome the limitations of cold storage, extensive research is focused on alternative normothermic preservation methods.
Ex vivo normothermic organ perfusion is an innovative preservation technique. The first experimental and clinical trials for ex vivo lung, liver, and kidney perfusions demonstrated favorable outcomes.
In addition to the reduction of cold ischemic injury, the method of normothermic kidney storage offers the opportunity for organ assessment and repair. This manuscript provides information about kidney retrieval, organ preservation techniques, and isolated ex vivo normothermic kidney perfusion (NEVKP) in a porcine model. Surgical techniques, set up for the perfusion solution and the circuit, potential assessment options, and representative results are demonstrated.

Normothermic Ex Vivo Kidney Perfusion for the Preservation of Kidney Grafts prior to Transplantation

The severe organ shortage has resulted in increased use of marginal kidney grafts for transplantation. This has triggered interest in alternative storage methods, since marginal grafts especially tolerate cold storage poorly. The technique of normothermic ex vivo kidney perfusion (NEVKP) represents a novel preservation method for kidney grafts prior to &#160;transplantation.

Kidney transplantation has become a well-established treatment option for patients with end-stage renal failure. The persisting organ shortage remains a ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Contractility Measurements of Human Uterine Smooth Muscle to Aid Drug Development

Discovery and characterization of novel pharmaceutical compounds or biochemical probes rely on robust and physiologically relevant assay systems. We describe methods to measure ex vivo myometrium contractility. This assay can be used to investigate factors and molecules involved in the modulation of myometrial contraction and to determine their excitatory or inhibitory actions, and hence their therapeutic potential in vivo. Biopsies are obtained from women undergoing cesarean section delivery with informed consent. Fine strips of myometrium are dissected, clipped and attached to a force transducer within 1 mL organ baths superfused with physiological saline solution at 37 &#176;C. Strips develop spontaneous contractions within 2&#8211;3 h under set tension and remain stable for many hours (&#62;6 h). Strips can also be stimulated to contract such as by the endogenous hormones, oxytocin and vasopressin, which cause concentration-dependent modulation of contraction frequency, force and duration, to more closely resemble contractions in labor. Hence, the effect of known and novel drug leads can be tested on spontaneous and agonist-induced contractions.
This protocol specifically details how this assay can be used to determine the potency of known and novel agents by measuring their effects on various parameters of human myometrial contraction. We use the oxytocin- and V1a receptor antagonists, atosiban and SR49059 as examples of known compounds which inhibit oxytocin- and vasopressin-induced contractions, and demonstrate how this method can be used to complement and validate pharmacological data obtained from cell-based assays to aid drug development. The effects of novel agonists in comparison to oxytocin and vasopressin can also be characterized. Whilst we use the example of the oxytocin/ vasopressin system, this method can also be used to study other receptors and ion channels that play a role in uterine contraction and relaxation to advance the understanding of human uterine physiology and pathophysiology.

This article describes experimental protocols to study ex vivo contractions of human myometrium and their application in drug discovery. This technique is used to improve the understanding of myometrial physiology and pathophysiology as well as to validate pharmacological data from novel research probes or drug leads.

Discovery and characterization of novel pharmaceutical compounds or biochemical probes rely on robust and physiologically relevant assay systems. We ...

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System

This manuscript describes the procedures to perform anogenital distance (AGD) and perineal measurements standardized by the Pelvic Organ Prolapse Quantification System (POP-Q): perineal body (PB) and genital hiatus (GH). These measurements are compared in women with and without pelvic organ prolapse.

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. ...

Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse

Here we present a protocol to examine the levator ani hiatus in males and females with pelvic organ prolapse, during the Valsalva maneuver and while evacuating acoustic gel, using a horizontally oriented 1.5 T magnetic resonance (MR) scanner. On midsagittal images, the vertical distance of pelvic organs is measured in millimeters relative to the hymen plane (female) and to the lower border of the symphysis pubis (male), preceded by - (above) or + ( below) signs. On axial images, the levator ani area is calculated in square centimeters with a free-hand tracing method from three key images, passing through the midsymphysis (level I), tangential to the lower border of the symphysis (level II), and at the maximal anterior rectal wall bulging (level III). Areas at rest and strained are compared to find evidence of a percentage of increase. The purpose is to provide objective evidence of the maximal extent of pelvic organs descent and hiatus enlargement without the interference of foreign objects or the examiner&#39;s proximity, so as to overcome the limitations of pelvic examination and transperineal sonography (i.e., subjectivity and sex-related limitations [female only]).

Here we present a protocol to standardize the measurement of the levator ani hiatus size&#160;by magnetic resonance imaging. The purpose is to extract biomechanical inferences from image analysis by comparing resting and straining values in patients of both sexes with pelvic prolapse, using consistent anatomical bony landmarks.

Here we present a protocol to examine the levator ani hiatus in males and females with pelvic organ prolapse, during the Valsalva maneuver and while ...

Orthotopic Kidney Auto-Transplantation in a Porcine Model Using 24 Hours Organ Preservation And Continuous Telemetry

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for kidney transplantation (KT). Even though, the use of allografts from extended criteria donors (ECD) could partially ease the shortage of organ donors, ECD organs carry a potentially higher risk for inferior outcomes and postoperative complications. Dynamic organ preservation techniques, modulation of ischemia-reperfusion and preservation injury, and allograft therapies are in the spotlight of scientific interest in an effort to improve allograft utilization and patient outcomes in KT.
Preclinical animal experiments are playing an essential role in translational research, especially in the medical device and drug development. The major advantage of the porcine orthotopic auto-transplantation model over ex vivo or small animal studies lies within the surgical-anatomical and physiological similarities to the clinical setting. This allows the investigation of new therapeutic methods and techniques and ensures a facilitated clinical translation of the findings. This protocol provides a comprehensive and problem-oriented description of the porcine orthotopic kidney auto-transplantation model, using a preservation time of 24 hours and telemetry monitoring. The combination of sophisticated surgical techniques with highly standardized and state-of-the-art methods of anesthesia, animal housing, perioperative follow up, and monitoring ensure the reproducibility and success of this model.

Large animal models play an essential role in preclinical transplantation research. Due to its similarities to the clinical setup, the porcine model of orthotopic kidney auto-transplantation described in this article provides an excellent in vivo setting for the testing of organ preservation techniques and therapeutic interventions.

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for ...

Fertility Preservation in Patients with Severe Ovarian Dysfunction

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, chemo- and radiation-therapies, as well as ovarian surgeries. In unmarried women with severe ovarian dysfunction, fertility preservation is important for future pregnancies. Although oocyte cryopreservation is an established method for fertility preservation, these patients could only preserve a limited number of oocytes even after ovarian hyperstimulation, leading to repeated stimulations to ensure sufficient oocytes to guarantee future pregnancy. To solve this issue, we have recently developed a drug-free in vitro activation (IVA) procedure, which enable us to stimulate early stages of ovarian follicles to develop to the preantral follicle stage. These preantral follicles can respond to the unique protocol of gonadotropin stimulation, resulting in increased number of retrieved oocytes per ovarian stimulation for cryopreservation. The drug-free IVA comprised from the surgical approach and ovarian stimulation. We removed a part of cortex from one or both ovaries from patients under laparoscopic surgery. The ovarian cortical tissues were cut into small cubes to disrupt the Hippo signaling pathway and stimulate the development of early stage follicles. These cubes were grafted orthotropically into remaining ovaries as well as beneath the serosa of both Fallopian tubes. We have already published the surgical procedure of the drug-free IVA and the protocol of subsequent ovarian stimulation, but herein we present the details of laboratory methods required for drug-free IVA.

We present details of laboratory procedures for drug-free in vitro activation (IVA) of ovarian follicles for patients with severe ovarian dysfunction. This method could increase the number of retrievable oocytes per ovarian hyperstimulation and benefit fertility preservation for those patients.

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

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Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse

Orthotopic Kidney Auto-Transplantation in a Porcine Model Using 24 Hours Organ Preservation And Continuous Telemetry

Fertility Preservation in Patients with Severe Ovarian Dysfunction

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction