{"paper_id":"1bc3384a-684d-47d0-932a-07f92a50b8d9","body_text":"O R I G I N A L A R T I C L E Open Access\nChronic pelvic pain and the role of\nexploratory laparoscopy as diagnostic\nand therapeutic tool: a retrospective\nobservational study\nGéraldine Brichant 1, Marie Denef 1, Linda Tebache 1, Gaëlle Poismans 1, Serena Pinzauti 2, Valérie Dechenne 1\nand Michelle Nisolle 1*\nAbstract\nBackground: Forty percent of exploratory laparoscopies are performed for chronic pelvic pain (CPP). However, a\nfinal diagnosis is still unreported in 35% of the patients. We decided to evaluate the identification of pathological\nlesions and the improvement of painful symptoms in patients with CPP and normal physical examination and\nimaging and who are scheduled for exploratory laparoscopy. The prospective study was designed in a tertiary\nreferral center for endometriosis. Forty-eight patients complaining of CPP and scheduled for exploratory\nlaparoscopy were included. Pelvic pain intensity was assessed using the visual analogue pain scale (VAS), and at\ninclusion, negative clinical and imaging assessments were required. During exploratory laparoscopy, the recognized\nlesions were reported and different surgical treatment options were performed depending on the location of the\nlesion.\nResults: In 98% of the cases, exploratory laparoscopy demonstrated the presence of pelvic anomalies that had not\nbeen diagnosed at the time of clinical and imaging examination. After surgery, a significant improvement of CPP\nhas been demonstrated in 24 (59%) patients with VAS < 5 postoperatively.\nConclusions: Exploratory laparoscopy is reasonable in patients complaining of CPP, allowing a final diagnosis in a\nhigh percentage of patients and a significant improvement in pain symptom in 59% of the cases. This study was\nretrospectively registered by our local Ethics Committee on February 7, 2018 (B412201835729).\nKeywords: Chronic pelvic pain, Exploratory laparoscopy, Endometriosis, Excision of uterosacral ligaments\nBackground\nChronic pelvic pain (CPP) is defined as intermittent or\nconstant pain lasting since at least 6 months in the lower\nabdomen or the pelvis. It can be localized in the pelvis,\nthe anterior abdominal wall at the umbilicus or below,\nand the lumbosacral back or the buttocks and is sufficient\nto cause functional disability or lead to seek medical care\n[1]. Almost 15% of women between 18 and 49 years old\ncomplain of CPP , but less than a third seek medical advice\n[2]. CPP is responsible for about 10% of gynecological\nconsultations and represents the surgical indication of\n40% of exploratory laparoscopies [ 1]. CPP may be related\nto different causes, from gynecological diseases to\ngastro-intestinal and urological pathologies. Although less\ncommon in such patients, neurological, musculoskeletal,\nand psychological diseases should be considered [ 3]. In 25\nto 50% of the cases, more than one anomaly can be found\nin a single patient, increasing the difficulties in diagnosing\nand alleviating the symptoms [ 4]. A full medical history,\nassociated with a complete medical examination, is key in\norder to address patients ’ correct diagnosis and manage-\nment. Nowadays, it becomes more and more obvious that\na multidisciplinary approach is one of the best way to help\nthe patient in an individualized manner [ 5].\n* Correspondence: michelle.nisolle@chrcitadelle.be\n1University Department of Obstetrics and Gynecology, CHR La Citadelle,\nBoulevard du Douzième de Ligne, 1, 4000 Liège, Belgium\nFull list of author information is available at the end of the article\nGynecological Surgery\n© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0\nInternational License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and\nreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to\nthe Creative Commons license, and indicate if changes were made.\nBrichant et al. Gynecological Surgery  (2018) 15:13 \nhttps://doi.org/10.1186/s10397-018-1045-5\n\nConsidering our experience, we found that patients ’\nhistory is often characterized by a long series of medical\nadvices and wrong diagnoses before the final treatment.\nThe present study aims to establish if exploratory lapar-\noscopy demonstrates the presence of pathological lesions\nin patients with normal physical and complementary ex-\naminations complaining of CPP and to evaluate the im-\nprovement of pain after the surgical procedures.\nMethods\nThis study took place in a tertiary referral Center for\nendometriosis, in the University department of Obstet-\nrics and Gynecology of Liège, Belgium, between October\n2011 and April 2015. A total of 48 patients complaining\nof CPP and scheduled for a surgical treatment were in-\ncluded in the present study following guidelines of our\nEthics Committee (B412201835729, retrospectively reg-\nistered February 7, 2018).\nIn order to evaluate the role and the efficacy of ex-\nploratory laparoscopy in patients with CPP , women in\nreproductive age (range 18 –45 years old) with CPP and\nnegative clinical and imaging examination were consid-\nered as possible candidates in the study. CPP was\nassessed using a 10-point visual analogue pain scale\n(VAS), and only women with a VAS ≥ 8 were included in\nthe study. Negative clinical examination or only a utero-\nsacral ligament (USL) thickening or uterine retroversion\nwere considered as inclusion criteria. All patients had\nhad a negative ultrasound from their referent OB-GYN.\nNegative imaging assessments, such as barium enema,\npelvic computerized tomography (CT), or pelvic mag-\nnetic resonance imaging (MRI), were also required at\ninclusion in the study. Exclusion criteria were an evi-\ndence of chronic disease at medical history or anatomic\nor endometriotic lesion on clinical examination and im-\naging assessments.\nAt inclusion, VAS score for chronic pelvic pain was\nnoted for each patient. During exploratory laparoscopy,\na complete examination of the abdominal and pelvic\ncavity was performed. The observed lesions were classi-\nfied as endometriosis, thickening of USLs with suspicion\nof endometriosis, adhesions, uterine anomalies, adnexal\nanomalies, or any other anomalies. Patients had been\ncounseled before surgery about the different treatment\noptions offered: excision of endometriosis, excision of\ntorus uterinum, adhesiolysis, total hysterectomy with or\nwithout bilateral salpingo-oophorectomy (SO), salpin-\ngectomy, oophorectomy, or any possible surgical treat-\nment. More than one lesion could be observed in each\npatient, and subsequently more than one surgical pro-\ncedure, performed. All specimens were sent for histo-\nlogical examination.\nAfter surgery, VAS score for chronic pelvic pain was\nassessed at 3- and 24-month interval during consultations.\nDepending on the VAS score, patients were divided into\nthe following four groups: group A: VAS 0, no pain; group\nB: VAS 1–4, mild pain; group C: VAS 5 –7, moderate pain;\nand group D: VAS 8 –10, severe pain.\nStatistical analysis\nData were collated in a secured data file and were ana-\nlyzed thanks to the Excel software. Results were expressed\nas mean ± standard deviation for continuous variable or as\npercentages for discrete variables. A p value < 0.05 was\nconsidered as statistically significant.\nResults\nThe characteristics of the patients are summarized in\nTable 1. Data were analyzed in 41 patients as 6 patients\nwere lost to follow-up, and in one case, laparoscopy was\nunsuccessful due to severe adhesions secondary to bowel\nresection for necrotizing enterocolitis in infancy, leading\nto unacceptable surgical risks. At exploratory laparos-\ncopy, the documented lesions were reported as follows:\n19 (46%) endometriotic lesions such as deep infiltrating\nendometriosis nodule or peritoneal lesions; 19 (46%)\nendometriotic suspected lesion (USL thickening); 14\n(31%) abdomino-peritoneal adhesions and adhesions be-\ntween the adnexa and bowel or uterus and bladder; 5\n(12%) uterine anomalies (increased uterine volume, ab-\nnormal vascularization, suspicion of adenomyosis); 7\n(17%) adnexal anomalies (non-dilated hydrosalpinx,\novarian cyst of small size); and 1 (2%) normal pelvis\n(Fig. 1 and Table 2). In summary, exploratory laparos-\ncopy demonstrated the presence of pelvic anomalies not\npreviously detected in 98% of patients.\nConsidering surgical procedures, we performed exci-\nsions of visible endometriosis 17 patients (41%); excisions\nof USLs in 24 patients (59%); adhesiolysis in 10 patients\n(24%); total hysterectomies (1 with unilateral SO and 4\nwithout) in 5 patients (12%); cystectomy, salpingectomies,\nSO, or other procedures on the adnexa in 7 patients\n(17%); excision of the post-hysterectomy vaginal scar in 2\nTable 1 Characteristics of patients\nCharacteristics Patients\nAge Range 18 –45 years old;\nmean 32 years old\nVAS score Mean 8.8/10 (± 0.9)\nComplementary examinations\n Barium enema\n Colonoscopy\n Pelvic computerized tomography (CT)\n Pelvic magnetic resonance imaging (MRI)\n27%\n5%\n17%\n68%\nMedical history of abdomino-pelvic surgery\n Endometriosis\n Other abdomino-pelvic surgery\n17%\n56%\nParity 46% nulliparous\nBrichant et al. Gynecological Surgery  (2018) 15:13 Page 2 of 7\n\npatients (5%); and treatment of uterine retroversion in 1\npatient (2%). In one patient (2%), no surgical procedure\nwas performed (Fig. 2 and T able 2). As previously men-\ntioned, more than one lesion could have been described in\na patient and subsequently more than one surgical pro-\ncedure would then be performed. In all cases but one,\nadhesiolysis has been always associated with another sur-\ngical procedure. In two thirds of the patients undergoing\nexcision of USLs, another procedure was performed. No\nintraoperative complications occurred during surgeries,\nand no abdominal conversion to laparotomy was needed.\nThe histological examination confirmed the presence\nof the corresponding pathological diseases in four cases\n(24%) of macroscopic endometriosis, in nine cases (38%)\nof suspected endometriosis (USL thickening), in five\ncases (100%) of uterine anomalies after hysterectomies\n(adenomyosis, salpingitis, leiomyomas, endometriosis),\nand in three cases (43%) of adnexal anomalies (Fig. 2).\nPostoperative pain was assessed, and patients were di-\nvided into four groups as previously mentioned: 18\npatients (44%) had no residual pain (VAS score 0), 6 pa-\ntients (15%) had mild pain (VAS score between 1 and 4), 8\npatients (19%) had moderate pain (VAS score between 5\nand 7), and 9 patients (22%) had severe pain with no\nimprovement of CPP and with VAS score ≥ 8( F i g .3).\nConsidering the single surgical procedures only, at the\ntime of endometriotic lesion resection, 10 (53%) patients\nreported a significant improvement of pain (group A\nand group B), while excision of USLs, adhesiolysis,\ncystectomy or salpingectomies or SO, and hysterec-\ntomy led to a considerable improvement of pain in 13\n(54%), 6 (60%), 5 (71%), and 5 (100%) of cases, respectively\n(Fig. 4 and T able2).\nDiscussion\nChronic pelvic pain is a debilitating condition among\nwomen with a major impact on health-related quality of\nlife, on work productivity, and on the health care system\nand concerns about 4% of women [ 1]. Identifying the\norigin of CPP is difficult as it may be caused by disorders\nof the reproductive tract, gastrointestinal system, uro-\nlogical organs, and musculoskeletal and psychoneurolo-\ngical systems [ 6]. Some conditions are often associated\nin the same patient, and many factors have to be evalu-\nated and be taken care of. Pelvic lesions discovered during\nexploratory laparoscopy are not necessarily responsible\nfor the pain described by the patient [ 2]. The medical his-\ntory and physical examination of the patient are essential\nto allow an appropriate management of the disease.\nGynecologic conditions account for approximately\n20% of cases of CPP [ 3, 7], and irritable bowel syndrome\n(IBS) and interstitial cystitis (IC) are the other most di-\nagnosed pathology [ 8]. Considering the different specific\ngynecological pathologies, several studies describe endo-\nmetriosis and adhesions as the most frequent causes of\nCPP (80 and 52%, respectively) [ 1, 2, 9]. In our series,\nthe high incidence of endometriosis and adhesions in\npatients with CPP was confirmed, accordingly with pre-\nvious results.\nHowever, if the association between painful symptoms\nand endometriosis or adhesions is well accepted, the pre-\ncise causal relationship is still poorly understood. Endo-\nmetriosis is still found in 2 –50% of asymptomatic women\n[4], confirming that the scientific research in this field re-\nmains a priority. The three most commonly suggested\nmechanisms for pain in endometriosis are the production\nof chemokines (growth factors and cytokines), the direct\nand indirect effects of active bleeding from endometriotic\nimplants, and the irritation or direct invasion of pelvic\nfloor nerves by infiltrating endometriotic lesions [ 10].\nCentral sensitization is also a mechanism involved in the\npain process in patients with endometriosis. Becker et al.\nshowed in their review that central changes might explain\nwhy pain could become more and more difficult to treat\nFig. 1 Pathological lesions documented during laparoscopy\nTable 2 Surgical procedures and number of patients improved\ndepending on the procedure\nSurgical procedures Number of patients:\nn (%)\nNumber of patients\nimproved (%)\nVisible endometriosis 17 (41%) 9 (53%)\nUSLs excisions 24 (59%) 13 (54%)\nAdhesiolysis 10 (24%) 6 (60%)\nTotal hysterectomies 5 (12%)\n(1 with unilateral SO)\n5 (100%)\nOther adnexal procedures:\n Cystectomy\n Salpingectomy\n SO\n others\n7 (17%) 5 (71%)\nExcision of post\nhysterectomy scar\n2 (5%) 1 (50%)\nUterine retroversion\ntreatment\n1 (2%) 1 (100%)\nNothing 1 (2%) 0 (0%)\nBrichant et al. Gynecological Surgery  (2018) 15:13 Page 3 of 7\n\ndespite appropriate medication. This could also explain\nthe gap sometimes existing between the extent of the dis-\nease and the importance of the pain and/or the persist-\nence of the pain despite extensive surgery [ 11]. However,\nas the authors stated, further studies targeting central\nchanges in women with proven endometriosis and their\ni n f l u e n c eo np a i ns y m p t o m sa n dt h er e s p o n s et ot r e a t -\nment are needed.\nNowadays, the relationship between deep infiltrating\nendometriosis (DIE) and painful symptoms is well con-\nsolidated, even if the extent of lesions does not correlate\nwith the severity of pain [ 12]. On the contrary, no strong\nevidence can be found for a relation between endome-\ntrioma and painful symptoms. Two reports suggested\nthat painful endometriomas are frequently associated\nwith pelvic adhesions, peritoneal implants, or deep infil-\ntrating lesions, and the severity of pain is independent\nfrom the size of the endometrioma [ 13, 14].\nEndometriotic lesions may have variable appearance.\nThe histological distinction in peritoneal, ovarian, and\ndeep-infiltrating endometriosis as three separate entities\nhas been well established [ 15]. Endometriotic lesions\nFig. 2 Surgical procedures performed during laparoscopy\nFig. 3 Pain improvement after surgery\nBrichant et al. Gynecological Surgery  (2018) 15:13 Page 4 of 7\n\nmay have typical aspects, purple or blue nodules, or\nmore atypical presentations in 15 –30% of patients\n(peritoneum opacification or circular defects, glandu-\nlar growths, inflammatory alterations, yellow spots,\novarian adhesions) that may be confused with other\nnon-endometriotic lesions [ 16]. Even if the gold standard\nfor endometriosis diagnosis remains the exploratory\nlaparoscopy, this technique in unexperienced hands may\nstill ignore some atypical or retroperitoneal endometriotic\nlesions. Nisolle et al. also showed that microscopic endo-\nmetriosis, invisible at the laparoscopic assessment, can be\ndiagnosed during anatomopathological analysis [ 17]. The\nold concept of microscopic endometriosis in visually nor-\nmal peritoneum reported more than a decade ago and\nsupported at that time by few series was recently con-\nfirmed by Khan et al. [ 18]. Clinical consequences of this\nendometriosis are unknown. However, some of the most\nrecent papers studying microscopic intestinal endometri-\nosis tend to be giving those tiny lesions some clinical rele-\nvance. Authors have proved the presence of microscopic\nendometriosis at a distance from macroscopic lesions that\nare resected. In those cases, radical segmental colectomy\nwould not be more efficient than discoid resection as it\nwould not remove the microscopic lesions [ 19, 20].\nIn summary, the increasing knowledge of the variabil-\nity of endometriotic lesions appearance has led to a sig-\nnificant increase in endometriosis diagnosis. However, a\nhigh incidence of indefinite diagnosis is still reported in\npatients with CPP as no visible pathology can be found\nin 35% of cases [ 9]. This proportion of failure to diag-\nnose an etiology for the CPP is high considering that ex-\nploratory laparoscopy remains an invasive surgical\nprocedure with the inherent risks. In our series, the rate\nof negative exploratory laparoscopy is extremely low\n(2%) and this data may be explained by the fact that all\npatients had been carefully examined and investigated by\na gynecologist specialized in CPP and endometriosis.\nThe same experimented gynecologist performed all\nsurgical procedures. From data about the lesions ’ appear-\nance, the development of other surgical procedures arises,\nsuch as the torus uterinum excision (or resection of utero-\nsacral ligament(s)). Surgery is performed by removing all\nthe USLs at the pararectal levels until their insertions on\nthe cervix. This technique should be differentiated from\nthe laparoscopic uterosacral nerve ablation (LUNA), con-\nsisting in a single uterosacral ligament section at 1 –2c m\nfrom their insertion on the cervix, and the pre-sacral\nneurectomy (PSN), consisting in the interruption of the\nsympathetic nervous fibers at the superior hypogastric\nplexus. Both LUNA and PSN are currently considered\nnon-specific procedure for CPP and are no longer recom-\nmended of these patients [ 9]. In our experience, torus\nuterinum excision has been performed in patients whose\nUSLs were tight and sore on clinical examination and/or\nif their thickened appearance was confirmed at the ex-\nploratory laparoscopy. More than half of our patients\ndescribed less pain after the surgery even if their satisfac-\ntion was not always related to the histological confirm-\nation of endometriosis. This procedure was efficient in\n54% (group A and B) even if the presence of endometri-\nosis was confirmed only for 5 patients on 13 (38%).\nOur data on histological examination confirmed the\npresence of endometriosis in only 24% of treated pa-\ntients for macroscopic endometriosis and in 38% of pa-\ntients with USLs excision. Actually, negative histological\nexamination cannot exclude endometriosis diagnosis be-\ncause either all rigorous histological criteria might not\nbe met or lesions might not visible because of hormonal\nsuppression or histological exploration might be incom-\nplete (i.e., small lesions surrounded by large sections of\nhealthy tissue). There is no consensus about technics for\nhistological examination. Histological examination is\nrecommended but a negative histological examination\ncannot exclude endometriosis diagnosis [ 21, 22].\nConsidering adhesions, as previously reported, they\nare frequently related to the endometriotic process and\nmay be actually considered as a possible cause of\npain-related endometriosis. Adhesions may theoretically\nbe caused by other pelvic inflammatory processes, such\nas pelvic inflammatory disease, inflammatory bowel dis-\nease, and previous abdominal-pelvic surgery but in 50%\nof cases the etiology is unknown [ 9]. The relationship\nbetween adhesions and CPP is controversial. Usually,\nstudies show a similar frequency of adhesions between\nwomen with CPP and without CPP [ 9]. However, some\nseries report some solid arguments in favor of a role of\nadhesions in CPP. Even as early as the 1980s, Kresch\nfound a higher frequency of adhesions in women with\nCPP compared with women without CPP. In his study,\nhe noted a characteristic aspect of adhesions in women\nwith CPP that appeared to be restricting the motion or\nthe expansibility of one or more organs [ 23]. More\nFig. 4 Pain postoperative improvement depending on the\nsurgical treatment\nBrichant et al. Gynecological Surgery  (2018) 15:13 Page 5 of 7\n\nrecently, the role of adhesions seemed to be confirmed\nby the laparoscopy conscious pain mapping where a\nlaparoscopy is performed under local anesthesia. The\nstudy showed that under local anesthesia stimulation of\nadhesions elicited pain in patients [ 24]. In our series, ad-\nhesions were described in 31% of patients with CPP and\nwe performed 10 (24%) of adhesiolysis with a significant\nimprovement of pain symptomatology (groups A and B) in\n60% of treated patients. Except in one case, this procedure\nhas been always associated to another surgical procedure\nand it seems difficult to make a judgment on its benefit.\nCPP represents 12% of all the indications for hysterec-\ntomy [25]. A recent review tells that in the absence of any\nobvious pathology, 60 to 79% of women report improve-\nment in symptomatology after hysterectomy. In our series,\nwe performed four (10%) total hysterectomies and one (2%)\ntotal hysterectomies with BSO when the uterus or adnexa\nhad abnormal aspect, such as increased volume, and abnor-\nmal vascularisation or fibroid appearance. Histological\nexamination confirmed pathologies such as adenomyosis,\nendosalpingiosis, salpingitis, endometritis, and leiomyoma\nin 100% of the specimen. All patients had significant im-\nprovement of pain after the procedure. Our data are similar\nto those of the literature, confirming that hysterectomy\nmay be effective against pain, even in the absence of obvi-\nous anomalies of the uterus. However, it should be import-\nant to inform patients that in 21 to 40% of the cases the\nintervention will not help in improving CPP and rarely will\nit worsen the painful symptomatology. Hysterectomy\nshould be categorized as a non-specific treatment. It should\nbe kept in mind that 70% of CPP are non-gynecologic eti-\nology such as irritable bowel syndrome, painful bladder\nsyndrome, and pelvic floor myalgia. All women with CPP\nshould undergo a multidisciplinary evaluation before sur-\ngery to exclude other causes of pain to maximize the\nchances of pain resolution [25].\nWe performed five (12%) interventions at adnexal level\nwith one cystectomy and one salpingo-oophorectomy\nfor cyst and three salpingectomies. Pelvic inflammatory\ndisease is found in 5% of laparoscopy performed to CPP.\nOne fourth of women who had acute salpingitis will de-\nvelop CPP. The aftereffect of acute salpingitis can be\nvariable and include adhesions, hydrosalpinx, and ovarian\ndystrophi [ 2]. Ovarian cysts are found in 3% of laparos-\ncopy performed for CPP. Ovarian cysts are usually asymp-\ntomatic or cause acute pain. Recurrent functional ovarian\ncysts seem to be sometimes the cause of CPP. In our\nseries, adnexal surgeries have been associated to another\nprocedure except in one case of the adnexectomy for a\ncyst. In all those cases, the patient is pain free (group A).\nConclusion\nIn conclusion, our study demonstrated that exploratory\nlaparoscopy provides a definitive diagnosis in 98% of\nwomen complaining of unexplained CPP. The surgical\ntreatment of these lesions improves painful symptom-\natology in 59% of women with a total disappearance of\npain in 44% of cases (VAS 0) and significant improve-\nment in 15% of cases (VAS < 5). We believe that the ex-\nploratory laparoscopy is therefore justified in patients\ncomplaining of significant CPP. The candidates ’ selection\nshould be meticulous, and patients should be investi-\ngated at urologic, gastroenterologic, and musculoskeletal\nlevel before surgery. We believe that women should be\nreferred to experimented gynecologists in the field of\nCPP and endometriosis who can properly inspect the\npelvic area and who are able to detect lesions potentially\nresponsible of CPP. Despite that, 22% of women do not\nimprove after surgery. This could either be because of\nthe found anomaly wasn ’t the only one responsible for\nthe painful symptoms and/or that normal anatomy\ncouldn’t be restored completely. We believe a better can-\ndidates’ selection including the identification of poor\nprognostic factor such as psychosomatic syndrome could\nimprove the results as well as a better identification of\nmacroscopic and microscopic conditions. A better un-\nderstanding of relationship between some type of lesions\nand CPP will help in alleviating the patients ’ symptoms.\nAbbreviations\nCPP: Chronic pelvic pain; CT: Computerized tomography; DIE: Deep\ninfiltrating endometriosis; IBS: Irritable bowel syndrome; IC: Interstital cystitis;\nLUNA: Laparoscopic uterosacral nerve ablation; MRI: Magnetic resonance\nimaging; PSN: Pre-sacral neurectomy; SO: Salpingo-oophorectomy;\nUSLs: Utero-sacral ligaments; VAS: Visual analogue pain scale\nAcknowledgements\nSpecial thanks to Marie Timmermans for her help in the data collection and\nanalysis.\nAvailability of data and materials\nPlease contact author for data requests.\nAuthors’ contributions\nGB, MD, GP, and SP have collected the data. MN and VD performed the\nsurgeries. GB, MD, and MN wrote the manuscript. All authors read and\napproved the final manuscript.\nEthics approval and consent to participate\nThis study was conducted according to the Ethical Guidelines of our institution,\nand no consent to participate was needed (Ethics Committee 412, CHR\nCitadelle, Liege, Belgium (study registration number: B412201835729)).\nConsent for publication\nNot applicable\nCompeting interests\nThe authors declare that they have no competing interests.\nPublisher’sN o t e\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional affiliations.\nAuthor details\n1University Department of Obstetrics and Gynecology, CHR La Citadelle,\nBoulevard du Douzième de Ligne, 1, 4000 Liège, Belgium. 2UO Ostetricia e\nGinecologia, Ospedale Santa Maria alla Gruccia, Arezzo, Montevarchi, Italy.\nBrichant et al. 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Obstet Gynecol 117:1175 –1178. https://doi.org/10.1097/AOG.\n0b013e31821646e1\nBrichant et al. Gynecological Surgery  (2018) 15:13 Page 7 of 7","source_license":"CC0","license_restricted":false}