We thank all the midwives and anesthesiologists who have collaborated on this project. David Sim&#243; has specially collaborated with this project recording the procedure.

This study was approved by the Clinic Research Committee of the &#34;Virgen de la Arrixaca&#34; at the University Clinical Hospital. Written informed consent was obtained from all participants.
1. Offer external cephalic version at consult (36 weeks)
<ol>
	<li>Identify the fetal position with an ultrasound.
	<ol>
		<li>Apply ultrasound gel on the patient&#8217;s abdomen.</li>
		<li>Place the abdominal probe on the hypogastric region.</li>
		<li>Identify the fetal position.</li>
	</ol>
	</li>
	<li>Offer external cephalic version.</li>
	<li>Have the patient sign informed consent.</li>
</ol>
2. Admit in the obstetric emergency room (&#8805;37 weeks)
<ol>
	<li>Identify the fetal position with an ultrasound.
	<ol>
		<li>Apply ultrasound gel on the patient&#8217;s abdomen.</li>
		<li>Place the abdominal probe on the hypogastric region.</li>
		<li>Identify the fetal position.</li>
	</ol>
	</li>
	<li>Prepare the patient and check requirements (blood test and informed consent).</li>
</ol>
3. Admit in the obstetric delivery room
<ol>
	<li>Perform cardiotocography assessment for fetal well-being.</li>
	<li>Add 10 mL of ritodrine in 500 mL of glucose solution.</li>
	<li>30 minutes before the procedure, administer 6 mg of ritodrine at 60 mL/h.</li>
	<li>Invite the patient to empty her bladder.</li>
	<li>Stop ritodrine perfusion before moving to the obstetric operating room.</li>
</ol>
4. External cephalic version procedure in obstetric operating room
<ol>
	<li>Move to the obstetric operating room.</li>
	<li>Monitor maternal vital signs (heartrate, EKG, temperature, noninvasive blood pressure, oxygen saturation).</li>
	<li>Identify the fetal position with an ultrasound.
	<ol>
		<li>Apply ultrasound gel on the patient&#8217;s abdomen.</li>
		<li>Place the abdominal probe on the hypogastric region.</li>
		<li>Identify the fetal position.</li>
	</ol>
	</li>
	<li>Position the patient in Trendelenburg (15&#176;).</li>
	<li>Perform analgesia.
	<ol>
		<li>Sedate the patient with 1-1.5 mg/kg propofol IV.</li>
		<li>Alternatively: Provide spinal anesthesia with 10 mL of 0.1% bupivacaine.</li>
	</ol>
	</li>
	<li>External cephalic version procedure (2 attempts)
	<ol>
		<li>Apply an abundant quantity of ultrasound gel on the patient&#8217;s abdomen.</li>
		<li>Place hands in the hypogastric region to identify the fetal buttocks (Obstetrician A).</li>
		<li>Elevate fetal buttocks (Obstetrician A).</li>
		<li>Place hands in the patient&#8217;s abdomen to locate the fetal head (Obstetrician B).</li>
		<li>Guide the fetal buttocks to the fundus (Obstetrician A).</li>
		<li>Consecutively direct the fetal head to the pelvis (Obstetrician B).</li>
	</ol>
	</li>
	<li>Identify the fetal well-being with ultrasound.
	<ol>
		<li>Place the abdominal probe on the abdomen.</li>
		<li>Identify the fetal heart.</li>
		<li>Observe the fetal heart rate for at least a minute.</li>
	</ol>
	</li>
	<li>Check for vaginal bleeding.</li>
	<li>Identify the fetal position with ultrasound.
	<ol>
		<li>Place the abdominal probe on the hypogastric region.</li>
		<li>Identify the fetal position.</li>
	</ol>
	</li>
</ol>
5. Move to obstetric delivery room
<ol>
	<li>Perform cardiotocography assessment for fetal well-being for at least 4 hours.</li>
	<li>Discharge the patient.</li>
</ol>
6. Admit in obstetric emergency room (24 h post-procedure)
<ol>
	<li>Perform cardiotocography assessment for fetal well-being for 30 minutes.</li>
</ol>

<ol><li>Melo, P., Georgiou, E. X., Hedditch, A., Ellaway, P., Impey, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((External+cephalic+version+at+term%3A+a+cohort+study+of+18+years%27+experience%5BTitle%5D)+AND+%22British+Journal+of+Obstetrics+and+Gynecology%22%5BJournal%5D)">External cephalic version at term: a cohort study of 18 years' experience.</a> British Journal of Obstetrics and Gynecology. 126, 493-499 (2019).</li>
<li>Hofmeyr, G. J., Kulier, R., West, H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((External+cephalic+version+for+breech+presentation+at+term%5BTitle%5D)+AND+%22Cochrane+Database+of+Systematic+Reviews%22%5BJournal%5D)">External cephalic version for breech presentation at term.</a> Cochrane Database of Systematic Reviews. 4, 83(2015).</li>
<li>Isakov, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prediction+of+Success+in+External+Cephalic+Version+for+Breech+Presentation+at+Term%5BTitle%5D)+AND+%22Obstetrics+and+Gynecology%22%5BJournal%5D)">Prediction of Success in External Cephalic Version for Breech Presentation at Term.</a> Obstetrics and Gynecology. 133 (5), 857-866 (2019).</li>
<li>Ebner, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Predictors+for+a+successful+external+cephalic+version%3A+a+single+centre+experience%5BTitle%5D)+AND+%22Archives+of+Gynecology+and+Obstetrics%22%5BJournal%5D)">Predictors for a successful external cephalic version: a single centre experience.</a> Archives of Gynecology and Obstetrics. 293 (4), 749-755 (2016).</li>
<li>Castañer-Mármol, A. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Results+of+external+cephalic+version+in+our+area+without+rutinary+tocolysis.+Review+and+implementation+strategy%22">Results of external cephalic version in our area without rutinary tocolysis. Review and implementation strategy</a>. , Public Health, Science History and gynecology Department.(Alicante, Miguel Hernández University). Dissertation (2015).</li>
<li>Burgos, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Probability+of+cesarean+delivery+after+successful+external+cephalic+version%5BTitle%5D)+AND+%22International+Journal+of+Gynecology+%26+Obstetrics%22%5BJournal%5D)">Probability of cesarean delivery after successful external cephalic version.</a> International Journal of Gynecology & Obstetrics. 131 (2), 192-195 (2015).</li>
<li>Muñoz, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((External+cephalic+version+at+term%3A+accumulated+experience%5BTitle%5D)+AND+%22Progresos+de+Obstetricia+y+Ginecolog%C3%ADa%22%5BJournal%5D)">External cephalic version at term: accumulated experience.</a> Progresos de Obstetricia y Ginecología. 48 (12), 574-580 (2005).</li>
<li>Velzel, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Atosiban+versus+fenoterol+as+a+uterine+relaxant+for+external+cephalic+version%3A+randomised+controlled+trial%5BTitle%5D)+AND+%22British+Medical+Journal%22%5BJournal%5D)">Atosiban versus fenoterol as a uterine relaxant for external cephalic version: randomised controlled trial.</a> British Medical Journal. 356 (26), 6773(2017).</li>
<li>Thissen, D., Swinkels, P., Dullemond, R. C., van der Steeg, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Introduction+of+a+dedicated+team+increases+the+success+rate+of+external+cephalic+version%3A+A+prospective+cohort+study%5BTitle%5D)+AND+%22European+Journal+of+Obstetrics+%26+Gynecology+and+Reproductive+Biology%22%5BJournal%5D)">Introduction of a dedicated team increases the success rate of external cephalic version: A prospective cohort study.</a> European Journal of Obstetrics & Gynecology and Reproductive Biology. 236 (3), 193-197 (2019).</li>
<li>Hindawi, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Value+and+pregnancy+outcome+of+external+cephalic+versi%C3%B3n%5BTitle%5D)+AND+%22Eastern+Mediterranean+Health+Journal%22%5BJournal%5D)">Value and pregnancy outcome of external cephalic versión.</a> Eastern Mediterranean Health Journal. 11 (4), 633-639 (2005).</li>
<li>Levin, G., Rottenstreich, A., Weill, Y., Pollack, R. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+bladder+volume+in+the+success+of+external+cephalic+version%5BTitle%5D)+AND+%22European+Journal+of+Obstetrics+%26+Gynecology+and+Reproductive+Biology%22%5BJournal%5D)">The role of bladder volume in the success of external cephalic version.</a> European Journal of Obstetrics & Gynecology and Reproductive Biology. 230, 178-181 (2018).</li>
<li>Vani, S., Lau, S. Y., Lim, B. K., Omar, S. Z., Tan, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intravenous+salbutamol+for+external+cephalic+version%5BTitle%5D)+AND+%22International+Journal+of+Gynecology+%26+Obstetrics%22%5BJournal%5D)">Intravenous salbutamol for external cephalic version.</a> International Journal of Gynecology & Obstetrics. 104, 28-31 (2009).</li>
<li>Sullivan, J. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+randomized+controlled+trial+of+the+effect+of+combined+spinal-epidural+analgesia+on+the+success+of+external+cephalic+version+for+breech+presentation%5BTitle%5D)+AND+%22International+Journal+of+Obstetric+Anesthesia%22%5BJournal%5D)">A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation.</a> International Journal of Obstetric Anesthesia. 18, 328-334 (2009).</li>
<li>Weiniger, C. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Randomized+controlled+trial+of+external+cephalic+version+in+term+multiparae+with+or+without+spinal+analgesia%5BTitle%5D)+AND+%22British+Journal+of+Anaesthesia%22%5BJournal%5D)">Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia.</a> British Journal of Anaesthesia. 104 (5), 613-618 (2010).</li>
<li>Grootscholten, K., Kok, M., Oei, S. G., Mol, B. W., van der Post, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((External+cephalic+version-related+risks%3A+a+meta-analysis%5BTitle%5D)+AND+%22Obstetrics+and+Gynecology%22%5BJournal%5D)">External cephalic version-related risks: a meta-analysis.</a> Obstetrics and Gynecology. 112 (5), 1143-1151 (2008).</li>
<li>Sociedad Española de Ginecología y Obstetricia. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((External+cephalic+version+%28updated+March+2014%29%5BTitle%5D)+AND+%22Progresos+de+Obstetricia+y+Ginecolog%C3%ADa%22%5BJournal%5D)">External cephalic version (updated March 2014).</a> Progresos de Obstetricia y Ginecología. 58 (7), 337-340 (2015).</li>
<li>Chaudhary, S., Contag, S., Yao, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+impact+of+maternal+body+mass+index+on+external+cephalic+version+success%5BTitle%5D)+AND+%22Journal+of+Maternal-Fetal+and+Neonatal+Medicine%22%5BJournal%5D)">The impact of maternal body mass index on external cephalic version success.</a> Journal of Maternal-Fetal and Neonatal Medicine. 32, 21-59 (2019).</li>
<li>de Hundt, M., Velzel, J., de Groot, C. J., Mol, B. W., Kok, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Mode+of+delivery+after+successful+external+cephalic+version%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Obstetrics+and+Gynecology%22%5BJournal%5D)">Mode of delivery after successful external cephalic version: a systematic review and meta-analysis.</a> Obstetrics and Gynecology. 123 (6), 1327-1334 (2014).</li>
<li>Krueger, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Labour+Outcomes+After+Successful+External+Cephalic+Version+Compared+With+Spontaneous+Cephalic+Version%5BTitle%5D)+AND+%22Journal+of+Obstetrics+and+Gynecology+Canada%22%5BJournal%5D)">Labour Outcomes After Successful External Cephalic Version Compared With Spontaneous Cephalic Version.</a> Journal of Obstetrics and Gynecology Canada. 40, 61-67 (2018).</li>
<li>Kean, L. H., Suwanrath, C., Gargari, S. S., Sahota, D. S., James, D. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comparison+of+fetal+behaviour+in+breech+and+cephalic+presentations+at+term%5BTitle%5D)+AND+%22British+Journal+of+Obstetrics+and+Gynecology%22%5BJournal%5D)">A comparison of fetal behaviour in breech and cephalic presentations at term.</a> British Journal of Obstetrics and Gynecology. 106, 1209-1213 (1999).</li>
</ol>

The authors have nothing to disclose.

This article shows the procedure to carry out the ECV. The ECV procedure success rate in this study is 82.5% (78.1-86.4%), which is higher than the success rate found in international literature 49.0% (47-50.9%)1,2,3,4 or Spanish literature 53.49% (42.9-64.0%)5,6,7. This difference may be due to the use of tocolytic agents before the procedure, as proposed by Velzel et al.8, the gestational age at which ECV is performed, the experience acquired by the four obstetricians who carry out the ECV at the center, as suggested by Thissen D et al.9, the use of analgesia or the presence of an anesthesiologist and a midwife.
The use of external cephalic version in breech presentation, according to WHO10, certainly reduces the incidence of caesarean section, which is of special interest in those units where vaginal breech delivery is not a common practice.
There are some crucial steps in the protocol that make it different from others. Having the patient empty her bladder before the procedure, the use of tocolysis only before the ECV or analgesia with propofol or spinal anesthesia may contribute to the higher success rate obtained in the study.
The bladder volume plays an important role in the ECV success. Levin et al.11 highlighted the importance of starting the procedure with an empty bladder, reporting an OR=2.5 (1.42-4.34) for successful ECV if the bladder had a volume below 400 mL. All the participants in this study had an empty bladder.
Additionally, we propose the use of tocolysis with a beta-adrenergic agonist only before the procedure as tocolysis makes moving the fetus during ECV easier. The use of tocolysis has been reported previously in different studies, often used before and during ECV procedure. Vani et al.12 have reported a RR=1.9 (1.3-2.8) for successful ECV if the beta-adrenergic agonist is used during ECV as opposed to not using it. However, the use of tocolysis solely before the procedure has not been reported.
We performed ECV under analgesia or spinal anesthesia. In such a way, contraction of abdominal wall muscles is avoided or reduced and making it easier to move the fetus during ECV. Sullivan et al.13 reported no differences in the ECV success rate when the use of combined spinal anesthesia with intravenous analgesia is compared with only spinal anesthesia. Weiniger et al.14 reported an OR=4.97 (1.41-17.48) for successful ECV when spinal anesthesia is performed against no anesthesia.
Tocolysis and analgesia not only make it easier to move the fetus during ECV, but also increase the risk of vaginal bleeding and placental abruptio. A limitation of the study that should be noted is that complications such as vaginal bleeding occurred in 2.5% (N=8) of the patients. Grootscholten et al.15 reported 0.38% (N=51) cases of vaginal bleeding or placental abruption.
The rate of complications obtained in this study is 5.94% (3.7-8.9%), which is similar to the rate found in literature 6.1%1,15. No more than two attempts are proposed to perform ECV in the protocol. The National Society of Gynecology and Obstetrics recommends no more than 4 attempts16 to avoid abruptio placentae and fetal heart rate disturbance. We have reduced this to 2 attempts in order to be more cautious with the procedure due to the fact that tocolysis and analgesia might induce the obstetricians to apply greater forces.
BMI has been studied as a factor with influence in the ECV success rate17. In the study, for every unit of BMI the success rate of the ECV was reduced 7.8% with an adjusted OR=0.942 (0.89-0.99). Moreover, in the study, patients with a BMI above 40 kg/m2 (N=4) have far less chances of success in ECV than patients with BMI lower than 25 kg/m2 with an adjusted OR=0.091 (0.009-0.89). The results are in accordance with S. Chaudhary et al.17 that describe a decrease in ECV success rate in patients with a BMI higher than 40 kg/m2 compared to those with a BMI between 18.5 and 24.9 kg/m2 with an adjusted OR=0.621 (0.54-0.71)17. This finding may be because the adipose panniculus that may make the procedure difficult.
In the study, the patients who underwent an ECV, independently of the result of the procedure, had an eutocic delivery in 42.9% (37.5-48.4%) of the cases, instrumented delivery in 21.1% (16.6-25.6%) of cases, urgent cesarean section during labor in 14.2% (10.7-18.4%) of cases, and elective cesarean section in 17.0% (13.2-21.5%) of cases. In the literature, patients who underwent an ECV, independently of the result of the procedure, had an eutocic delivery in 33.1% (31.3-34.9%)1,2,18,19 of the cases, instrumented delivery in 10.5% (9.3-11.7%)1,2,18,19 of the cases, urgent cesarean section during labor in 18.5% (17.0-20.0%)1,2,18,19 of the cases, and elective cesarean section in 36.6% (34.7-38.5%)1,2,18,19 of the cases. Therefore, the study has a higher eutocic and instrumented delivery rate and a lower urgent cesarean section during labor rate than the literature reports. These differences might stem from the fact that the ECV success rate in this study is higher than published in the literature, therefore the vaginal delivery rate we obtained is also greater. It also should be noted that the differences in eutocic, instrumented and cesarean delivery rates could be explained due to the conservative management of the labor that is carried out in this center, so a higher spontaneous onset of labor, and a higher vaginal delivery rate are achieved with this approach.
After an ECV, the instrumented delivery rate increased compared to the general population, as de Hundt et al.18 described. In the study, ECV is associated with an instrumented delivery with OR=1.63 (1.22-2.17), while some authors18 reported an OR=1.4 (1.1-1.7). The reasons why women after a successful ECV have an increased risk for instrumented delivery compared with the general pregnant population remain unclear. Some studies have reported that breech fetuses are biologically different from cephalic-presenting fetuses with a lower weight, lower fetoplacental ratio and smaller head circumference18,20. These suggest that breech fetuses might tolerate labor worse and show earlier signs of fetal distress.
In the literature1,2,3,4, many factors are considered to influence in ECV success rate such as parity, amniotic fluid index, posterior placenta and breech presentation. However, we have just found a statistical association between parity and ECV success rate with an adjusted OR=3.029 (1.62-5.68) and maternal BMI with an adjusted OR=0.942 (0.89-0.99). Other factors have been associated with the failure of ECV such as: maternal age, gestational age at ECV, previous cesarean and estimated fetal weight1,2,3,4. However, no significantly statistical associations were found in the study. Future investigation is needed to evaluate different protocols of ECV including previous aspect and analgesia method.
Finally, we can conclude that ECV is an effective procedure to reduce the number of cesarean sections in fetuses with breech presentations. Maternal BMI and previous vaginal delivery are associated with success in ECV. Successful ECV does not modify the usual delivery pattern in comparison with the general population.

An erratum was issued for:&#160;<a href="https://www.jove.com/t/60636">External Cephalic Version: Is it an Effective and Safe Procedure?</a>. Figure 1 was updated from:
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60636/60636fig1.jpg" /> 
Figure 1: Comparison of type of delivery: General pregnant population in 2018, ECV cohort between 2014-2018, Successful ECV cohort between 2014-2018. * Chi-squared test: p&#60;0.05. <a href="https://www.jove.com/files/ftp_upload/60636/60636fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
to:
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60636/60636fig1v3.jpg" /> 
Figure 1: Comparison of type of delivery: General pregnant population in 2018, ECV cohort between 2014-2018, Successful ECV cohort between 2014-2018. * Chi-squared test: p&#60;0.05. <a href="https://www.jove.com/files/ftp_upload/60636/60636fig1v2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

An erratum was issued for:&#160;<a href="https://www.jove.com/t/60636">External Cephalic Version: Is it an Effective and Safe Procedure?</a>. Figure 1 was updated.

Erratum: External Cephalic Version: Is it an Effective and Safe Procedure?

External cephalic version (ECV) is a procedure for modifying the fetal position and achieving a cephalic presentation. The objective of the ECV is to offer an opportunity for cephalic delivery to occur, which is widely known to be safer than breech or cesarean section. ECV is usually performed before the active labor period begins. Factors associated with a higher ECV success rate include1,4: multiparity, a transverse presentation, black race, posterior placenta, amniotic fluid index higher than 10 cm.
However, ECV is not an innocuous procedure and may present7,11 intraversion complications such as premature rupture of membranes, vaginal bleeding, transitory changes of fetal heart rate, cord prolapse, abruptio placentae, even stillbirth.
In this article, we analyzed ECVs performed under analgesia and tocolysis. To date, no video report has been published showing how to perform this procedure with analgesia and tocolysis. The main objective of this study is to show how ECV is performed. We also describe some key actions that could improve the procedural success. As a secondary objective, we analyzed the results of ECV obtained following the specific protocol with tocolysis and analgesia and compared the results with the literature. We also analyzed factors associated with ECV success rate, type of delivery and a comparison of the type of delivery in ECV pregnant women with non-ECV pregnant women were also included.

<table><tbody><tr><td>Avalon FM20 Fetal monitor</td><td>Koninklijke Philips N.V</td><td></td><td>https://www.usa.philips.com/healthcare/product/HC862198/avalon-fm20-fetal-monitor</td></tr><tr><td>Convex Array Probe 4C-RS</td><td>General Electric Health Care Company</td><td></td><td></td></tr><tr><td>Aquasonic&amp;reg; 100 Ultrasound Transmission Gel</td><td>Parker Laboratories, INC</td><td></td><td>https://www.parkerlabs.com/aquasonic-100.asp</td></tr><tr><td>Propofol Lipuro (10 mg/mL Inject 20 mL)</td><td>B. Braun Medical, SA</td><td></td><td></td></tr><tr><td>Ritodrine Pre-par (10 mg/mL)</td><td>Laboratorio Reig Jofr&amp;eacute;, S.A</td><td></td><td></td></tr><tr><td>Viridia series 50 XM Fetal Monitor</td><td>Koninklijke Philips N.V</td><td></td><td>https://www.usa.philips.com/healthcare/product/HC865071/avalon-fm50-fetal-monitor</td></tr><tr><td>Voluson P6&amp;nbsp;</td><td>General Electric Health Care Company</td><td></td><td>https://www.ge-sonostore.com/en/voluson/p6</td></tr></tbody></table>

external cephalic version: is it an effective and safe procedure?

External cephalic version (ECV) is an effective procedure for reducing the number of cesarean sections. To date, there is no video publication showing the methodology of this procedure. The main objective is to show how to perform ECV with a specific protocol with tocolysis before the procedure and analgesia. Moreover, we describe and analyze the factors associated with successful ECV, and also compare to deliveries in the general pregnant population.
A retrospective and descriptive analysis of ECV carried out at the Hospital Clinico Universitario Virgen de la Arrixaca in Murcia (Spain) between 1/1/2014 and 12/31/2018 was assessed. The latest data available of labor deliveries in the local center, which is the biggest maternity department in Spain, were from 2018.
320 patients were recruited and 3 pregnant women were lost during the study. ECV was carried out at 37&#177;3 weeks gestation. ECV was successful in 82.5% (N=264). 19 complications were reported (5.9%): 8 vaginal bleeding (2.5%), 9 fetal bradycardia (2.8%), 1 preterm rupture of membranes (0.3%) and 1 cord prolapse (0.3%). A previous vaginal delivery increases the success rate of ECV ORadjusted=3.03 (1.62-5.68). Maternal Body Mass Index (BMI) affects the success of ECV ORadjusted=0.94 (0.89-0.99). Patients with BMI&#62;40 kg/m2 have an ORadjusted=0.09 (0.009-0.89) compared with those with BMI &#60;25 kg/m2. If ECV was successful, the cesarean delivery index is 22.2% (17.5-27.6%), the eutocic delivery index is 52.1% (46.1-58.1%) and the instrumented vaginal delivery index is 25.7% (20.7-31.2%). There are no differences in cesarean and eutocic delivery indexes after successful ECV. However, a successful ECV is associated with a 6.29% increase in the instrumented delivery rate (OR=1.63).
ECV is an effective procedure to reduce the number of cesarean sections for breech presentations. Maternal BMI and previous vaginal delivery are associated with ECV success. Successful ECV does not modify the usual delivery pattern.

Three hundred and twenty patients were recruited between January 1, 2014 and December 31, 2018. Three patients were lost during the follow-up after the ECV because delivery was not carried out in our hospital.
Statistics were derived from the raw data. To study the differences between groups, unpaired Student&#39;s t-tests were used for quantitative variables and chi-square tests for dichotomous variables. All tests were two-tailed at a 0.05 significance level.
The mean age of all the patients was 33.18 years. 55.6% of the patients were nulliparous. Only 13 patients (4.1%) had a previous cesarean section. The mean maternal BMI was 25.1 kg/m2. The placenta was located in anterior wall of uterus in 63.5% of the patients, posterior in 30.8%, in fundus in 3.5% and in the lateral wall in 2.2%.
The ECV were performed at 37&#177;3 weeks gestation, as an average, and the indication of ECV was breech presentation in 92.2% (N=295) of the patients and transverse presentation in 7.8% (N=25). ECV was successful in 82.5% (N=264) and failed in 17.5% (N=56) [Table 1]. Intraversion complications occurred in 5.94% (N=19) of the procedures: 9 had fetal bradycardia for more than 6 min (2.81%), 8 had vaginal bleeding (2.5%), 1 had preterm rupture of the membranes during the following 24 hours (0.31%), and 1 had cord prolapse (0.31%). No newborns were hospitalized in the neonatal unit nor the neonatal intensive care unit (NICU).
The factors related with the ECV procedure success in the logistic regression multivariant model (Table 3) were previous vaginal delivery with an adjusted OR=3.029 (1.62-5.68) and BMI with an adjusted OR=0.942 (0.89-0.99). Pregnant women with a previous vaginal delivery were 2.03 times more likely to have ECV success than nulliparous. If BMI was categorized (Table 4), patients with a BMI above 40 kg/m2 had an adjusted OR=0.091 (0.009-0.89) if they were compared with those with a BMI lower than 25 kg/m2 whereas a one unit increase in maternal BMI was associated with a 5.8% decrease in ECV success rate.
In the 261 successful ECV patient cohort (Table 2), 59.39% (N=155) of the patients had a spontaneous onset of labor, induction in 34.87% (N=91) of the patients, elective non-scheduled cesarean in 1.53% (N=4) of the patients due to unstable presentation, and intraversion cesarean in 4.21% (N=11) of the patients. 77.8% (N=203) of successful ECV patients ended the pregnancy with a vaginal delivery, in contrast with 22.2% (N=58) that had a cesarean delivery (including elective non-scheduled cesarean, intraversion cesarean section and urgent cesarean section during labor).
The type of delivery of the 261 successful ECV patients are shown in Table 2 and Figure 1: eutocic in 52.1% (N=136), instrumented in 25.7% (N=67), urgent cesarean section during labor in 16.5% (N=43), elective non-scheduled cesarean section in 1.5% (N=4) and intraversion cesarean section in 4.2% (N=11).
In patients with successful ECV, nulliparity was the only factor statistically associated with instrumented delivery with an adjusted OR=9.09 (4.54-18.20) following the logistic regression multivariant model (Table 2). Meanwhile, the BMI was the only factor statistically associated with an urgent cesarean section with an adjusted OR=1.11 (1.03-1.19).
Although, in the hospital during the 2018, 7,040 deliveries were carried out, just 7009 of them were correctly recorded in data base (Figure 1): 4136 (59.0%) were eutocic, 1309 (18.7%) were instrumented and 1564 (22.3%) had cesarean delivery.
In patients with a successful ECV (Table 2 and Figure 1), the cesarean section rate was 17.5% (11.9-23.0%), in contrast with general population cesarean section rate of 22.3% (21.3-23.3%). No statistical differences were found between successful ECV and general population cesarean section rate, OR=0.74 (0.53-1.03).
In patients with successful ECV, the eutocic delivery rate was 52.1% (46.1-58.1%), in comparison with the general population eutocic delivery rate of 59.0% (57.9-60.2%) [Table 2 and Figure 1]. No statistical differences were found between the successful ECV and the general population eutocic delivery rate, OR=0.86 (0.67-1.11).
In patients with a successful ECV, the instrumented delivery rate was 25.7% (20.7-31.2%), in contrast with the general population instrumented delivery rate of 18.7% (17.8-19.6%) [Table 2 and Figure 1]. Successful ECV was statistically associated with an increase of instrumented delivery rate if compared with the general population, OR=1.63 (1.22-2.17).
Between 2014 and 2018, 36,068 deliveries were carried out in the hospital, 7,423 of them were via cesarean section (20.6%). Thus, the ECV procedure has avoided 203 elective cesarean section during that period, a 0.56% decrease in the cesarean section rate.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60636/60636fig1v3.jpg" /> 
Figure 1: Comparison of type of delivery: General pregnant population in 2018, ECV cohort between 2014-2018, Successful ECV cohort between 2014-2018. * Chi-squared test: p&#60;0.05. <a href="https://www.jove.com/files/ftp_upload/60636/60636fig1v2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td colspan="2" rowspan="3"></td>
			<td colspan="4">ECV Result</td>
		</tr>
		<tr>
			<td colspan="2">Success</td>
			<td colspan="2">Fail</td>
		</tr>
		<tr>
			<td>Mean/% (N)</td>
			<td>CI 95%</td>
			<td>Mean/% (N)</td>
			<td>CI 95%</td>
		</tr>
		<tr>
			<td colspan="2">Age</td>
			<td>33.3</td>
			<td>(32.7-34.0)</td>
			<td>32.5</td>
			<td>(31.0-33.9)</td>
		</tr>
		<tr>
			<td colspan="2">Gestational age at ECV</td>
			<td>37.4</td>
			<td>(37.3-37.5)</td>
			<td>37.3</td>
			<td>(37.2-37.4)</td>
		</tr>
		<tr>
			<td colspan="2">Gravity</td>
			<td>2.1</td>
			<td>(1.9-2.3)</td>
			<td>1.7</td>
			<td>(1.4-2.1)</td>
		</tr>
		<tr>
			<td colspan="2">Parity</td>
			<td>0.8</td>
			<td>(0.6-0.9)</td>
			<td>0.5</td>
			<td>(0.2-0.7)</td>
		</tr>
		<tr>
			<td colspan="2">Nulliparity</td>
			<td>51.9% (137)</td>
			<td>(45.9-57.9%)</td>
			<td>73.2% (41)</td>
			<td>(60.7-83.4%)</td>
		</tr>
		<tr>
			<td colspan="2">Previous cesarean section</td>
			<td>3.8% (10)</td>
			<td>(2.0-6.6%)</td>
			<td>5.4% (3)</td>
			<td>(1.5-13.6%)</td>
		</tr>
		<tr>
			<td colspan="2">Maternal BMI</td>
			<td>24.8</td>
			<td>(24.2-25.4)</td>
			<td>26.4</td>
			<td>(24.8-28.0)</td>
		</tr>
		<tr>
			<td rowspan="5">Categorized Maternal BMI</td>
			<td>Normal weight</td>
			<td>57.1% (145)</td>
			<td>(51.0-63.1%)</td>
			<td>54.9% (28)</td>
			<td>(41.3-68.0%)</td>
		</tr>
		<tr>
			<td>Overweight</td>
			<td>31.1% (79)</td>
			<td>(25.7-37.0%)</td>
			<td>23.5% (12)</td>
			<td>(13.6-36.4%)</td>
		</tr>
		<tr>
			<td>Obesity grade 1</td>
			<td>8.7% (22)</td>
			<td>(5.7-12.6%)</td>
			<td>11.8% (6)</td>
			<td>(5.1-22.7%)</td>
		</tr>
		<tr>
			<td>Obesity grade 2</td>
			<td>2.8% (7)</td>
			<td>(1.2-5.3%)</td>
			<td>3.9% (2)</td>
			<td>(0.8-12.0%)</td>
		</tr>
		<tr>
			<td>Obesity grade 3</td>
			<td>0.4% (1)</td>
			<td>(0.04-1.8%)</td>
			<td>5.9% (3)</td>
			<td>(1.7-14.9%)</td>
		</tr>
		<tr>
			<td colspan="2">Estimated Fetal Weight before ECV (g)</td>
			<td>2818.7</td>
			<td>(2773.9-2863.5)</td>
			<td>2801.5</td>
			<td>(2715.3-2887.8)</td>
		</tr>
		<tr>
			<td rowspan="5">Placental location</td>
			<td>Anterior</td>
			<td>62.7% (165)</td>
			<td>(56.8-68.4%)</td>
			<td>67.3% (37)</td>
			<td>(54.2-78.5%)</td>
		</tr>
		<tr>
			<td>Posterior</td>
			<td>31.6% (83)</td>
			<td>(26.1-37.4%)</td>
			<td>27.3% (15)</td>
			<td>(16.9-40.0%)</td>
		</tr>
		<tr>
			<td>Fundus</td>
			<td>3.4% (9)</td>
			<td>(1.7-6.2%)</td>
			<td>3.6% (2)</td>
			<td>(0.8-11.2%)</td>
		</tr>
		<tr>
			<td>Lateral wall</td>
			<td>2.3% (6)</td>
			<td>(1.0-4.6%)</td>
			<td>1.8% (1)</td>
			<td>(0.2-8.2%)</td>
		</tr>
		<tr>
			<td>Previa</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td rowspan="2">ECV Indication</td>
			<td>Breech</td>
			<td>90.9% (240)</td>
			<td>(87.0-93.9%)</td>
			<td>98.2% (55)</td>
			<td>(92.0-99.8%)</td>
		</tr>
		<tr>
			<td>Transverse</td>
			<td>9.1% (24)</td>
			<td>(6.1-13.0%)</td>
			<td>1.8% (1)</td>
			<td>(0.2-8.0%)</td>
		</tr>
		<tr>
			<td rowspan="3">Analgesia</td>
			<td>No</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td>Sedation</td>
			<td>98.9% (261)</td>
			<td>(97.0-99.7%)</td>
			<td>100% (56)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td>Spinal anesthesia</td>
			<td>1.1% (3)</td>
			<td>(0.3-3.0%)</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
		</tr>
	</tbody>
</table>
Table 1: External Cephalic Version characteristics: Success or Fail ECV. %: percentage. CI 95%: confidence interval 95%.
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td colspan="3" rowspan="3"></td>
			<td colspan="4">ECV Result</td>
		</tr>
		<tr>
			<td colspan="2">Success</td>
			<td colspan="2">Fail</td>
		</tr>
		<tr>
			<td>Mean/% (N)</td>
			<td>CI 95%</td>
			<td>Mean/% (N)</td>
			<td>CI 95%</td>
		</tr>
		<tr>
			<td colspan="3">Gestational age at delivery</td>
			<td>39.0</td>
			<td>(38.4-39.6)</td>
			<td>39.0</td>
			<td>(38.7-39.3)</td>
		</tr>
		<tr>
			<td rowspan="4">Onset of labor</td>
			<td colspan="2">Spontaneous</td>
			<td>59.4% (155)</td>
			<td>(53.4-65.2%)</td>
			<td>1.8% (1)</td>
			<td>(0.2-8.0%)</td>
		</tr>
		<tr>
			<td colspan="2">Induction</td>
			<td>34.9% (91)</td>
			<td>(29.3-40.8%)</td>
			<td>1.8% (1)</td>
			<td>(0.2-8.0%)</td>
		</tr>
		<tr>
			<td colspan="2">Elective cesarean</td>
			<td>1.5% (4)</td>
			<td>(0.5-3.6%)</td>
			<td>89.3% (50)</td>
			<td>(79.2-95.4%)</td>
		</tr>
		<tr>
			<td colspan="2">Intraversion cesarean</td>
			<td>4.2% (11)</td>
			<td>(2.3-7.2%)</td>
			<td>7.1% (4)</td>
			<td>(2.5-16.1%)</td>
		</tr>
		<tr>
			<td rowspan="5">Type of delivery</td>
			<td colspan="2">Vaginal</td>
			<td>77.8% (203)</td>
			<td>(72.5-82.5%)</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td></td>
			<td>Eutocic</td>
			<td>52.1% (136)</td>
			<td>(46.1-58.1%)</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td></td>
			<td>Instrumented</td>
			<td>25.7% (67)</td>
			<td>(20.7-31.2%)</td>
			<td>0% (0)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td colspan="2">Cesarean</td>
			<td>22.2% (58)</td>
			<td>(17.5-27.6%)</td>
			<td>100% (56)</td>
			<td>(0-0%)</td>
		</tr>
		<tr>
			<td></td>
			<td>Urgent cesarean</td>
			<td>16.5% (43)</td>
			<td>(12.4-21.3%)</td>
			<td>3.6% (2)</td>
			<td>(0.8-11.0%)</td>
		</tr>
		<tr>
			<td colspan="3">ECV complications</td>
			<td>5.7% (15)</td>
			<td>(3.4-9.0%)</td>
			<td>7.1% (4)</td>
			<td>(2.5-16.1%)</td>
		</tr>
		<tr>
			<td colspan="3">Newborn weight (g)</td>
			<td>3276.9</td>
			<td>(3218.4-3335.3)</td>
			<td>3154.7</td>
			<td>(3050.2-3259.2)</td>
		</tr>
	</tbody>
</table>
Table 2: Onset of labor and type of delivery. External Cephalic Version characteristics: Success or Fail ECV. %: percentage. CI 95%: confidence interval 95%.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2"></td>
			<td>OR</td>
			<td>p</td>
			<td>95% CI</td>
			<td>adjustedOR</td>
			<td>p</td>
			<td>95% CI</td>
		</tr>
		<tr>
			<td colspan="2">Previous vaginal delivery</td>
			<td>3.467</td>
			<td>0.001</td>
			<td>(1.684-7.140)</td>
			<td>3.029</td>
			<td>0.001</td>
			<td>(1.615-5.680)</td>
		</tr>
		<tr>
			<td colspan="2">Maternal BMI</td>
			<td>0.911</td>
			<td>0.007</td>
			<td>(0.851-0.975)</td>
			<td>0.942</td>
			<td>0.044</td>
			<td>(0.888-0.998)</td>
		</tr>
		<tr>
			<td colspan="2">Previous cesarean section</td>
			<td>0.706</td>
			<td>0.619</td>
			<td>(0.179-2.786)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td rowspan="4">Placental location</td>
			<td>Anterior</td>
			<td>0.000</td>
			<td>0.523</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Posterior</td>
			<td>1.559</td>
			<td>0.218</td>
			<td>(0.770-3.157)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Fundus</td>
			<td>2.640</td>
			<td>0.375</td>
			<td>(0.310-22.499)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Lateral</td>
			<td>0.732</td>
			<td>0.783</td>
			<td>(0.080-6.679)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Estimated Fetal Weight before ECV (g)</td>
			<td>1.000</td>
			<td>0.441</td>
			<td>(0.999-1.001)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 3: Logistic regression multivariant model of ECV results. OR: Odds ratio. 95% CI: 95% confidence interval. BMI: Body mass index. OR adjusted by previous vaginal delivery and maternal BMI.
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td></td>
			<td>OR</td>
			<td>p</td>
			<td>95% CI</td>
		</tr>
		<tr>
			<td>Maternal BMI less than 25 Kg/m2</td>
			<td>1.000</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Maternal BMI between 25-30 Kg/m2</td>
			<td>1.378</td>
			<td>0.342</td>
			<td>(0.711-2.673)</td>
		</tr>
		<tr>
			<td>Maternal BMI between 30-35 Kg/m2</td>
			<td>0.816</td>
			<td>0.668</td>
			<td>(0.322-2.067)</td>
		</tr>
		<tr>
			<td>Maternal BMI between 35-40 Kg/m2</td>
			<td>0.952</td>
			<td>0.953</td>
			<td>(0.190-4.778)</td>
		</tr>
		<tr>
			<td>Maternal BMI above 40 Kg/m2</td>
			<td>0.091</td>
			<td>0.040</td>
			<td>(0.009-0.897)</td>
		</tr>
	</tbody>
</table>
Table 4: ECV results compared with categorized Body Mass Index. OR: Odds ratio. 95% CI: 95% confidence interval. BMI: Body Mass Index.

Watch this Scientific Journal Video about External Cephalic Version: Is it an Effective and Safe Procedure? at JoVE.com

External Cephalic Version: Is it an Effective and Safe Procedure?

This article shows how to perform the external cephalic version (ECV) by two experienced obstetricians in the obstetric operating room in the presence of an anesthesiologist and a midwife. The ECV is carried out with analgesia and tocolysis. Two attempts are made under ultrasonography control.

External cephalic version (ECV) is an effective procedure for reducing the number of cesarean sections. To date, there is no video publication showing the ...

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Universidad Científica del Sur

Research

JoVE Journal

Medicine

14.4K Views.  University Clinical Hospital. This article shows how to perform the external cephalic version (ECV) by two experienced obstetricians in the obstetric operating room in the presence of an anesthesiologist and a midwife. The ECV is carried out with analgesia and tocolysis. Two attempts are made under ultrasonography control.

Video: External Cephalic Version: Is it an Effective and Safe Procedure?

Vessel-sparing Excision and Primary Anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling

Breastfeeding can be challenging for mother-infant dyads experiencing biomechanical suckling difficulties. Although lactation consultants (LCs) all over the world have increased their skills in this field and can provide support to help position the infant at the breast, the impact of their intervention might be limited in the presence of stiff structures in the infants. Here we present a protocol for a randomized controlled trial to assess the efficacy of osteopathic treatment, coupled with lactation consultation, for infants&#39; biomechanical suckling difficulties. It proposes a set-up and a sequence of actions to ensure an optimal context for treatment, as well as a blinding of parents and LCs to the intervention. Data such as the infant&#39;s latch ability measured with the LATCH Assessment Tool, the mother&#39;s nipple pain with a visual analog scale (VAS), and the mother&#39;s perceptions are collected by LCs four times over a 10-day period. Osteopathic lesions are documented by the osteopath, using a standardized assessment grid. Structures of interest are coherent with the anatomical zones involved in latching onto the breast. This protocol also proposes a strategy to document systematically an osteopathic profile of infants with biomechanical suckling difficulties in their first weeks of life. The implementation of this protocol confirms its feasibility for osteopathic assessment and treatment and paves the way for future trials to further explore the efficacy of osteopathic techniques for infants with biomechanical suckling difficulties.

Osteopathy is an emerging field of clinical research. Here we present a protocol to assess the efficacy of an osteopathic intervention coupled with lactation consultation, in infants with biomechanical issues impeding breastfeeding.

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Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of epididymal OA since 2000. There are two challenges in classic microscopic vasoepididymostomy. First, anastomosis of the vas deferens and epididymis is performed with double-needle sutures. However, there is a lack of good-quality and cost-effective double-needle sutures in China, which leads to increased difficulty and poor success rates of anastomosis. Second, the separation of the vas deferens does not retain vasculature, although the vas deferens vasculature plays an important role in the blood supply to the vas deferens, epididymis, and testis. This affects the blood supply to the anastomotic area and epididymis.
Therefore, this team has made innovative improvements to address these problems. Good-quality, cost-effective, single-needle sutures, which are easy to purchase in China and other countries, were used in microsurgical longitudinal intussusception vasoepididymostomy. This can optimize the operation procedure and shorten the operation time while ensuring the success rate of the anastomosis. The surgical method of preserving the vas deferens vessels was innovatively proposed because the etiology of epididymal OA is mostly inflammatory in China. The protection of the blood supply to the vas deferens and epididymis is maximized using microsurgical forceps to separate and protect the vasculature. Patency reached 81.7% in the postoperative follow-up, indicating a better surgical treatment effect.

The present protocol describes a vessel-sparing, longitudinal intussusception vasoepididymostomy using readily available single-needle sutures in China, a safe and effective procedure, which may improve patients' patency and natural pregnancy rates.

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of ...

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure and be meaningful for patients who have undergone varicocelectomy. Nevertheless, preserving the vasal vessels might elevate the risk of increasing the tension of anastomosis, affecting the patency rate and leading to delayed postoperative bleeding. Therefore, we developed a novel vessel-sparing MVE to make it safer. Here is a summary of the improvements to the procedure. 1) The retrograde dissociation of the vasal vessels on the proximal testicular side was adopted as the main method, and the anterograde dissociation of the vasal vessels on the distal testicular side was adopted as a supplement to dissociate the vasal vessels to be preserved. This improvement ensures the blood supply to the vas deferens that will be used for anastomosis and also provides longer vasal vessels, which reduces the tension of anastomosis. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed, which resolves the problem of transmission of vas tension to the vasal vessels and reduces the risk of vasal vessel hemorrhage. 3) Dissociation of the vas deferens after opening the tunica vaginalis increases the mobilization of the vas deferens, which also makes the new procedure easier to complete. The evaluation of the outcomes of this new procedure showed that no significant postoperative complications occurred in the patients, and the patency rate was no different from that of the conventional procedure. Therefore, this new, improved procedure can be considered safe, with satisfactory postoperative results.

Here, we present a protocol to preserve the vasal vessels in microsurgical vasoepididymostomy. The surgical security is enhanced by preserving the vasal vessels using a retrograde-anterograde dissociation and fixing the vasal vessels.

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, ...

Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ventriculoperitoneal (VP) shunt is the most common type. Unfortunately, the failure rates of VP shunts are alarmingly high, with up to 50% of patients requiring revision surgery within 2 years. VP shunt failure may occur due to infection, or catheter mispositioning, migration, and occlusion. We undertook a joint neurosurgery and general surgery collaboration in a 7-year prospective non-randomized consecutive quality improvement cohort study to reduce the rates of ventriculoperitoneal (VP) shunt failures in 224 adult patients at a tertiary care institution. The initiative combined the use of electromagnetic stereotactic neuronavigation to guide the placement of the proximal catheter and laparoscopy to place the distal catheter under direct visualization. With laparoscopic assistance, the distal catheter was anchored through a small hole created in the falciform ligament and placed into the right retrohepatic space, free from the omentum, adhesions, or bowel that might obstruct the catheter tip. The surgeries were performed using a shunt infection prevention protocol to reduce the risk of shunt infections. Here, we present an intraoperative video of the surgical procedure. Compliance with shunt infection reduction strategies and the combined utilization of neuronavigation and laparoscopy techniques in adult VP shunt surgery resulted in a 44% reduction in the risk of overall shunt failure. The significant positive impact with regard to shunt-failure-free patient outcomes among patients who underwent VP shunt surgery using this strategy underscores the value associated with the use of these modern intraoperative techniques and cross-specialty collaboration during VP shunt surgery.

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively.

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ...

Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane

We present the preliminary results of a longitudinal observational study aimed at evaluating the effectiveness and safety at different short- and long-term follow-ups of vascular occlusion of the great saphenous vein (GSV) and small saphenous vein (SSV) affected by severe pathological reflux, using an innovative modified cyanoacrylate surgical glue composed of N-butyl cyanoacrylate and methacryloxy sulfolane (NBCA+MS). Ninety patients, prospectively recruited for 1 year, underwent the study with EcoColor-Doppler (ECD) to evaluate the maximum diameters of the GSV and SSV in the orthostatic position and the reflux time (RT). An RT greater than 0.5 s was considered pathologic. Clinical, etiology, anatomy, and pathophysiology (CEAP) assessment was used for the complete evaluation of each patient in the study. All the patients were treated by NBCA+MS glue to obtain vein occlusion and observed before treatment (baseline; T0), within 6 h after treatment (T1), 1 month after treatment (T2), 3 months after treatment (T3), 6 months after treatment (T4), and 1 year after treatment (T5). Chi-square (&#967;) analysis was performed to evaluate the effectiveness and safety of the treatment. All the patients participated in the entire duration of the study. Complete occlusion was maintained in 100% of patients at T1, 98.9% at T2 and T3, and 97.8% at T4 and T5 (p &lt; 0.001). None of the patients suffered from post-surgical thrombosis. No blue hyperpigmentation, or paresthesia was observed during the entire observation period. Immediately after treatment, 7.7% of patients needed painkillers; 1 week after treatment, 100% of patients returned to normal life. Vascular occlusion of the great or small saphenous vein using NBCA+MS glue is a safe procedure with persistent benefits after a 1 year follow-up. This procedure can be performed with local anesthesia, allowing a quick return to normal life. Thanks to its low invasiveness, the treatment is not painful.

Here, we present a protocol to treat the great saphenous vein (GSV) and the small saphenous vein (SSV) affected by severe pathological reflux, using an original sclerosing and embolizing cyanoacrylate-based glue composed of N-butyl cyanoacrylate and methacryloxy sulfolane (NBCA+MS).

We present the preliminary results of a longitudinal observational study aimed at evaluating the effectiveness and safety at different short- and ...

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...

Unilateral Biportal Endoscopy for the Treatment of Lumbar Disc Herniation

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such as lumbar disc herniation, lumbar spinal stenosis, and spondylolisthesis. In UBE, two independent yet interconnected surgical channels are established-one for the endoscope and the other for surgical instruments-providing a broad and clear surgical field of view. UBE offers several advantages over traditional open surgery, including reduced tissue damage, shorter hospital stays, and faster recovery times. Additionally, it combines the benefits of microscopic surgery and interlaminar endoscopy, enhancing flexibility, accuracy, and reliability during the procedure. The learning curve for UBE is shorter than that for transforaminal endoscopy, as the surgical processes closely resemble those of conventional open surgery. Despite its favorable clinical outcomes, such as reduced blood loss and shorter hospitalization, UBE carries potential complications, including epidural hematoma, dural injury, and compression of the outlet nerve root. To mitigate these risks, it is crucial to ensure appropriate patient selection, apply the correct surgical technique, and engage in careful postoperative monitoring. This article provides a detailed summary of the step-by-step surgical techniques used in UBE for treating lumbar disc herniation. It serves as a comprehensive guide to enhance practitioners' understanding of UBE. The presentation also underscores the importance of rigorous training and expertise to ensure optimal patient outcomes.

Presented here is a step-by-step surgical protocol of unilateral biportal endoscopy (UBE), a minimally invasive approach for treating lumbar disc herniation. By using two ports, surgical accuracy and flexibility are enhanced. This article provides a comprehensive description of UBE and highlights the practical application of this approach in clinical practice.

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such ...

Electrical Stimulation Therapy: Non-Surgical Remedy for Varicocele-Induced Pain

Transcutaneous Neuromuscular Electrical Stimulation for Treating Varicocele-Induced Scrotal Pain

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological studies have shown that varicocele occurs in approximately 10% to 15% of adult males, while scrotal pain affects 2% to 10% of the population. Currently, clinical treatment options for varicocele-induced scrotal pain include general therapy, medication, and surgery. Among these, surgical intervention is considered the most effective method, boasting a success rate of 80%. However, it carries risks such as postoperative bleeding, infection, and recurrence, making it less desirable for some patients. In recent years, transcutaneous neuromuscular electrical stimulation has gained wide acceptance for treating various andrological conditions, including erectile dysfunction and premature ejaculation, yielding positive outcomes. This non-invasive technique offers a promising alternative for managing varicocele-induced scrotal pain, potentially reducing the need for surgical intervention and its associated risks. Its growing popularity underscores the need for further research and clinical trials to validate its efficacy and safety in treating this condition.

Author Spotlight: Advancing Varicocele Treatment with Neuromuscular Electrical Stimulation

This protocol outlines the use of transcutaneous neuromuscular electrical stimulation for treating varicocele-induced scrotal pain. It compares visual analog scale (VAS) scores and imaging changes before and after treatment to assess effectiveness. Results indicate that patients experienced improved scrotal pain symptoms following the treatment.

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological ...