A Multimodal Concept for Vaginal Cuff Closure by Modification of the Bakay Technique in Total Laparoscopic Hysterectomy: A Randomized Clinical Study

A Multimodal Concept for Vaginal Cuff Closure by Modification of the Bakay Technique in Total Laparoscopic Hysterectomy: A Randomized Clinical Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Multimodal Concept for Vaginal Cuff Closure by Modification of the Bakay Technique in Total Laparoscopic Hysterectomy: A Randomized Clinical Study Üzeyir Kalkan, Kadir Bakay This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-841945/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2022 Read the published version in BMC Women's Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background: The aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH). Methods: This two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed. Results: Seventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (59 vs. 55.5 min, respectively; p=0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range, 6 to 12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range, 1 to 4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p=0.456). The mean uterine weight for the ST group and MT group was comparable (258.6±88.6 g vs. 232.9±102.5 g, respectively; p=0.107). The preoperative vaginal length was not significantly different between the groups (p=0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p= 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range, 1 to 5) in both groups (p=0.636). The complication rates were similar between the groups (p=0.230). Conclusion: The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support. Health Economics & Outcomes Research Health Policy Laparoscopic cuff closure Laparoscopic hysterectomy Bakay technique Cold colpotomy Figures Figure 1 Figure 2 Introduction Although the benefits of laparoscopy including less postoperative discomfort, short recovery time, and improved patient outcomes are well documented in the literature [ 1 ], there are many factors still limiting the wide acceptance and implementation of the technique for hysterectomy [ 2 ]. The most challenging steps of total laparoscopic hysterectomy (TLH) are colpotomy and cuff closure. The basis for minimizing the rate of severe haemorrhage and ureteral injuries, the most serious events related to these steps, is meticulous dissection providing a clear operative field and the skill and experience of the surgeon. In TLH, the altered anatomy after the removal of the uterus may cause the retraction of vagina and shifting of neighbouring structures such as bladder and/or bowel to this pouch, thereby, leading to obstruction of the operative field for vaginal cuff closure [ 3 , 4 ]. Electrosurgical colpotomy is usually the preferred technique in TLH. However, this may cause more extensive tissue necrosis and devascularization, leading to a thicker inflammatory infiltrate and late tissue healing ( i.e. , per secundam intentionem). This prolonged inflammatory phase may increase the risk of cuff cellulitis, dehiscence, granulation and secondary haemorrhages. Therefore, it is of utmost importance to put the sutures beyond the demarcation line of this thermal damage to for tissue integrity [ 5 ]. The apical uterovaginal support is compromised by total hysterectomies [ 6 ]. Unless re-attachment of the uterosacral ligament (USL) complex to vaginal cuff is performed, Level I support is lost, potentially leading to future vaginal vault prolapse [ 7 , 8 ]. A concomitant procedure for apical support performed during hysterectomy lowers the re-operation rates for pelvic organ prolapse in the future [ 9 ]. Despite this, apical support procedures appear to be underutilized: they are performed in only 3% and 55% of cases without and with a diagnosis of uterovaginal prolapse [ 10 ]. The American Association of Gynecologic Laparoscopists (AAGL) also recommends USL suspension at the time of TLH to prevent future vaginal vault prolapse [ 11 ]. To date, various methods of cuff closure in TLH have been described [ 4 , 12 , 13 ]. Bakay [ 14 ] published his novel colpotomy and cuff closure technique for TLH in 2018.This study was the first to describe placing a single continuous running purse-string suture facilitating the cuff closure before colpotomy. The main advantage of the technique involved retrieving the safe suture margins required for vaginal cuff closure before the pelvic anatomy was altered by the removal of the uterus. In addition to this advantage, we modified the technique to achieve a better cuff healing and standardized apical support and the modified Bakay technique (MT) proposes: i) placing a single continuous running purse-string suture for vaginal cuff closure before the pelvic anatomy is altered by the colpotomy and removal of the uterus; ii) suspension/plication of USLs (as a well-defined, efficient, concomitant apical support procedure to prevent future vaginal vault prolapse) routinely in each case before colpotomy while the margins of these ligaments and adjacent structures such as ureters are still prominent and pelvic anatomy is not altered; and iii) using cold-knife colpotomy instead of electrosurgical colpotomy to support the primary healing of the vaginal cuff. In the present study, we aimed to compare the surgical and clinical outcomes of the MT to standard technique (ST) in patients undergoing TLH. Materials And Methods Study design and study population This two centre, randomized clinical study was conducted at Departments of Obstetrics and Gynaecology of two tertiary care centres between November 2018 and September 2020. The patients who were scheduled to undergo TLH for benign diseases were screened. Pelvic examination, transvaginal ultrasound, Pap-smear and endometrial biopsy, urine analysis, blood analysis including complete blood count, prothrombin time and partial thromboplastin time, and electrocardiography were performed preoperatively. Prior to study, all patients were informed about the nature of the study. A written informed consent was obtained from each patient. The study protocol was approved by the institutional Science and Ethics Committee (Application Date: 23.02.2018 and Approval No: OMU KAEK 2018/22). The study was conducted in accordance with the principles of the Declaration of Helsinki. ClinicalTrials.gov registration number is NCT05080114 and the first posted date was 15/10/2021. The patients who fulfilled the inclusion criteria were allocated into two groups by a computer-based randomization programme as ST group (n=80) and MT group (n=80). The main indications for surgery were symptomatic uterine fibromatosis, chronic pelvic pain, simple or complex endometrial hyperplasia, menorrhagia/adenomyosis, or benign adnexal masses. Patients with anaesthetic contraindications to laparoscopy, premalignant or malignant genital disease, prior pelvic and/or abdominal radiotherapy, large adnexal masses; large fibroids obscuring the visualization of the cervicovaginal junction; suspicion of malignancy; and pelvic organ prolapse Stage >2 were excluded. All procedures were performed by two gynaecologic surgeons who are both skilled and experienced in laparoscopic surgery. Definitions and outcome measures The operative time was defined as the time interval between the placement and removal of the primary trocar. As the sequence of colpotomy, removal of uterus and cuff suturing steps are different in each technique, operative times of colpotomy, extraction of uterus, and vaginal cuff closure steps were each added for comparison. Blood loss was measured by examining the amount of blood aspirated during the procedure. Preoperative vaginal length measurements were taken during the first preoperative vaginal examination in the relaxed dorsal lithotomy position by wooden tongue depressors scaled before. The distance from posterior vaginal vault to hymen was recorded as the vaginal length. Postoperative vaginal length measurements and Patient Global Impression of Improvement (PGI-I) questionnaire was performed on Day 90 postoperatively. The PGI-I questionnaire consisting of the question “How is your postoperative condition now, compared to how it was before you had the surgery?” was filled by the patient in the waiting room before the pelvic examination on Day 90. The response for the question ranges from 1 to 7 with lower scores indicating a greater level of satisfaction. Postoperative complications were recorded during follow-up visits on Day 7, 30, and 90. Classification of complications was made based on the standardized Clavien-Dindo reporting system [15]. Surgical procedure All operations were performed under general anaesthesia with nasogastric intubation and a bladder catheter in place. Cefazolin 2 g was administered to all patients for prophylaxis 30 min prior to surgery. Operations were performed with a 10-mm laparoscope (Karl Storz, Germany) through the trocar placed usually in the umbilicus. Two lateral 5-mm trocars and one midline 10-mm trocar were used. The placement of trocars varied according to the uterine size. Haemostasis was usually performed using bipolar forceps (Karl Storz Robi, Germany), whereas dissection was performed using the LigaSure™ (Covidien, Medtronic, USA) Maryland jaw laparoscopic sealer/divider, bipolar forceps and scissors. In both groups, all the steps of the TLH leading to colpotomy were performed according to standard protocol. However, the sequence and technique of the remaining steps in the MT group were different as follows: A 0 Monocryl™ violet (poliglecaprone 25) or a 0 PDS II (polydioxanone) suture with a 36-mm needle (Ethicon Inc., NJ, USA) through the 10-mm midline trocar was placed first on the right USL, proximal to the ischial spine, usually 1 to 3 cm away from its uterine insertion, then helically proceeded by 1 to 3 bite(s) (depending on the length of the ligament) for suspension/plication. The suture continued circumferentially in the counterclockwise direction on the line between the cervicovaginal junction and the bladder in a full-thickness purse string fashion, paying attention not to get closer than 1 cm to the bladder. This suture symmetrically ended in the left USL, across the point of the start, again by completing the last bite(s) helically for suspension/plication, forming nearly an Ohm sign (Ω). Once accomplished, suture ends were pulled outside by the assistant surgeon via the10-mm port for retraction and further extracorporeal knot tying; or left inside and grasped by an instrument for further intracorporeal knot tying. This gentle retraction was also intended to slightly pull the suture ends in case of a bleeding that might occur during the cold scissor/knife colpotomy. Colpotomy was performed circumferentially using laparoscopic cold scissors and/or knife, maintaining a safe distance from the suture line, paying attention not to cut the suture. The detached uterus was, then, removed vaginally and both ends of the prior suture line were knotted securely. The steps are summarized in Figure 1. The closed vaginal cuff was manually examined for any defects under endoscopic visualization. No additional sutures were used. The first video (Video 1) shows the procedure of a case with no history of abdominal operations. The second video (Video 2) shows a case with a history of caesarean section. All patients were informed to refrain from sexual intercourse for at least 60 days after the operation. Main outcomes Demographic and clinical data, history of previous surgery, and intra- and postoperative findings were recorded. Operative time (time interval between the placement and removal of primary trocar); total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps; uterine weight (measured before immersion in formaldehyde); blood loss (estimate of the fluid aspirated during the procedure); and length of hospital stay were also noted. The complications were recorded by the clinical evaluation of the patients on Day 7, 30, and 90 postoperatively. Pre- and postoperative vaginal length and patient satisfaction were evaluated. Statistical analysis Statistical analysis was performed using the SPSS version 23.0 software (IBM Corp., Armonk, NY, USA). Descriptive data were presented in mean ± standard deviation (SD), median (min-max) or number and frequency, where applicable. Normal distribution of variables was tested using the Kolmogorov-Smirnov test. Independent samples t -test was used to compare normally distributed data, while the Mann-Whitney U was used to compare data that did not show normal distribution. The chi-square test was used for the comparison of categorical data. A p value of <0.05 was considered statistically significant. Results A total of 174 patients scheduled to undergo TLH for benign diseases were screened. Eleven patients refused to participate and three patients were excluded due to anaesthetic contraindications to laparoscopy. Finally, 160 patients who met the inclusion criteria were allocated into two groups by a computer-based randomization programme as ST group and MT group. Of 80 patients allocated for ST group, 10 patients were dropped out (n=7 not attending to the visit on Day 90, n=3 having a diagnosis of deep infiltrating endometriosis requiring discoid vaginal wall resection during TLH). Among 80 patients allocated for MT group, only two patients were dropped out, as they did not attend to visit on Day 90. Finally, a total of 70 patients in the ST group and 78 patients in the MT group were included in the analysis. The CONSORT study flow chart [ 16 ] is shown in Figure 2 . Age, body mass index (BMI), parity, menopausal status, history of pelvic surgery, and indications for laparoscopic surgeries did not differ significantly between the groups (Table 1 ). The median age for ST group and MT group was 46 (range, 35 to 56) and 47 (range, 36 to 59) years, respectively. The median BMI for ST group and MT group was 28.1 (range, 19,2 to 40,6) and 26.8 (range, 19,2 to 42,1) kg/m 2 respectively. For both groups, the median parity was 2 (range, 0 to 5). In ST group, 35 (50%) patients and, in MT group, 45 (57.7%) patients had history of pelvic surgery. In ST group 21 (30%) patients and, in MT group, 27 (34.6%) patients were in the postmenopausal period. The ST was performed due to indications of abnormal uterine bleeding and adenomyosis in 21 (30%), myoma in 31 (44.3%), endometrial polyps in five (7.1%), chronic pelvic pain in three (4.3%), adnexal masses in six (8.6%), and simple or complex endometrial hyperplasia in four (5.7%) women. The MT was performed due to abnormal uterine bleeding and adenomyosis in 17 (21.8%), myoma in 34 (43.6%), endometrial polyps in seven (9%), chronic pelvic pain in five (6.4%), adnexal masses in 11 (14.1%), and simple or complex endometrial hyperplasia in four (5.1%) women. There were no conversions to laparotomy in either group. Table 1 Demographic data of the patients and indications for surgery. Standard technique group (n=70) Modified Bakay technique group (n=78) Total (n=148) Test statistics p Age (yr) 46 (35 - 56) 47 (36 - 59) 47 (36 - 59) U=2673 0,826 BMI (kg/m 2 ) 28,1 (19,2-40,6) 26,8 (19,2-42,1) 27,4 (19,2-42,1) U=2651,5 0,763 Parity 2 (0 - 5) 2 (0 - 5) 2 (0 - 5) U=2463 0,291 History of pelvic surgery Yes 35 (50) 45 (57,7) 80 (54,1) χ2=0,879 0,348 No 35 (50) 33 (42,3) 68 (45,9) Indications for hysterectomy χ2=2,438 0,786 Menorrhagia and Adenomyosis 21 (30) 17 (21,8) 38 (25,7) Myoma 31 (44,3) 34 (43,6) 65 (43,9) Endometrial polyp 5 (7,1) 7 (9) 12 (8,1) Adnexal mass 6 (8,6) 11 (14,1) 17 (11,5) Chronic pelvic pain 3 (4,3) 5 (6,4) 8 (5,4) Simple or complex hyperplasia 4 (5,7) 4 (5,1) 8 (5,4) Menopausal status χ2=0,359 0,549 Premenopause 49 (70) 51 (65,4) 100 (67,6) Postmenopause 21 (30) 27 (34,6) 48 (32,4) U: Mann Whitney U test, \({ \chi }^{2}\) : Chi-square test Operative data and outcome measures are shown in Table 2 . The median operative time for ST group was 59 (range, 50 to 75) min and 55.5 (range, 34 to 80) min for the MT group. The operative time was significantly shorter in the MT group (p=0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure was equal in both groups (9 min for both groups). In both groups, the median length of hospital stay was 2 (range, 1 to 4) days. The median intraoperative blood loss was 90 mL in the ST group and 80 mL in the MT group, indicating no statistically significant difference (p=0.456). The mean uterine weight for the ST group and MT group was 258.6±88.6 g and 232.9±102.5 g, respectively, indicating no statistically significant difference (p=0.107). The median preoperative vaginal length was not significantly different between the groups (p=0.502). However, the median postoperative vaginal length on Day 90 was significantly higher in the MT group compared to the ST group (8 [6 to 9.5] cm vs. 7.5 [5.5 to 9] cm, respectively; p= 0.001)). The median patient satisfaction as measured by PGI-I scale on Day 90 was 2 (range, 1 to 5) in both groups, indicating no statistically significant difference (p=0.636). Table 2 Surgical data and outcome measures. Standard technique group (n=70) Modified Bakay technique group (n=78) Total (n=148) Test statistics p Operative time (min) 59 (50 - 75) 55,5 (34 - 80) 57 (34 - 80) U=1885,5 0,001 * Intraoperative blood loss (ml) 90 (60 - 150) 80 (60 - 180) 90 (60 - 180) U=2536,5 0,456 Lenght of hospital stay (d) 2 (1 - 4) 2 (1 - 4) 2 (1 - 4) U=2716 0,949 Uterine weight (g) 258,6 ± 88,6 232,9 ± 102,5 245 ± 96,7 t=1,623 0,107 Total operative time for colpotomy, extraction of uterus, and vaginal cuff closure (min) 9 (6 - 11) 9 (6 - 12) 9 (6 - 12) U=2533,5 0,441 Intraoperative and postoperative complications Yes 6 (8,6) 3 (3,8) 9 (6,1) χ2=1,442 0,230 No 64 (91,4) 75 (96,2) 139 (93,9) Preoperative vaginal length (cm) 8 (6,5 - 10) 8,5 (6,5 - 10) 8 (6,5 - 10) U=2559 0,502 Postoperative vaginal length (cm) 7,5 (5,5 - 9) 8 (6 - 9,5) 7,5 (5,5 - 9,5) U=1854,5 0,001 * Patient satisfaction by PGI-I scale on day 90 postoperatively 2 (1 - 5) 2 (1 - 5) 2 (1 - 5) U=2614 0,636 U: Mann Whitney U test, t: Independent samples t test; \({\chi }^{2}\) : Chi-square test; * : p value<.05 The complication rates were not significantly different between the groups (p=0.230). There was one bladder injury, one urinary tract infection and one trocar site infection in each group. Bladder injuries were detected and repaired intraoperatively. The trocar site and urinary infections were successfully treated with proper antibiotherapy. In the ST group, additionally, one patient had fever (>38 ° C) who was successfully treated with antibiotic and antipyretics, one patient had ileus who was successfully treated with conservative measures such as oral restriction, antiemetics, and electrolyte solution infusions, and one patient had cuff granulation who was diagnosed on Day 60 and treated by electrocoagulation under local anaesthesia. Complications are listed in Table 3 . Table 3 Intraoperative and postoperative complications. Clavien-Dindo classification Standard technique group (n=70) Modified Bakay technique group (n=78) Total (n=148) Intraoperative and postoperative complications (%) Bladder injury Grade 3b 1 (1,4) 1 (1,3) 2 (1,4) Urinary tract infection Grade 2 1 (1,4) 1 (1,3) 2 (1,4) Trocar site infection Grade 2 1 (1,4) 1 (1,3) 2 (1,4) Fever Grade 2 1 (1,4) 0 1 (0,7) Ileus Grade 1 1 (1,4) 0 1 (0,7) Cuff granulation Grade 3a 1 (1,4) 0 1 (0,7) Discussion Various techniques for vaginal cuff incision and closure in TLH have been described in the literature [ 4 , 12 , 13 ]. In this study, the Bakay technique [ 14 ] was modified to achieve a routine concomitant effective apical support to prevent future vaginal vault prolapse, and primary healing of the vaginal cuff by using cold-knife colpotomy, instead of electrosurgical colpotomy, in addition to the former objective of the technique that was vaginal cuff closure with safe suture margins before the pelvic anatomy was altered by the removal of the uterus. The clinical and surgical outcomes of the MT showed successful results compared to ST. Colpotomy and cuff closure steps are technically the most difficult and prolonged parts of TLH. Additionally, the most frequent complications of TLH, which are ureteral injury and bleeding, mostly occur in these steps. One of the main advantages of the MT involves placing the sutures before the pelvic anatomy is altered by the colpotomy/removal of the uterus providing to maintain the required suture margins with a safe distance from the bladder, ureters, and bowels in a shorter total operating time. To the best of our knowledge, there is no study specifically comparing cold-knife colpotomy with electrosurgical colpotomy at TLH. During the colpotomy, monopolar current when applied at 60 W for 1 s exhibits a mean critical spread of 3.5 mm; however, the spread exceeds 20 mm when applied for ≥2 s [ 17 ]. Thus, a more prolonged continuous current may increase the extent of collateral damage. Current recommendations for colpotomy and cuff closure in TLH are to minimize lateral thermal spread to maintain tissue integrity and to place sutures well beyond the border of thermal damage to prevent vaginal cuff dehiscence and evisceration [ 18 ]. In MT, using cold-knife colpotomy, instead of electrosurgical colpotomy, we intended to eliminate extensive tissue necrosis and devascularization leading to a thicker inflammatory infiltrate and late tissue healing (per secundam intentionem). As a point of good practice, this may contribute to prevent cuff cellulitis, cuff dehiscence, and secondary cuff haemorrhages by supporting the primary healing of the vaginal cuff. Also, our technique may tolerate the smaller purchases on vaginal cuff being sutured caused by the laparoscopic magnification of the surgical field. In this study, there was no significant difference in the postoperative complication rates between the groups, although the sample size is too small to specifically compare the rate of complications such as cuff cellulitis, dehiscence, granulation, and secondary cuff haemorrhages. This may be the subject of a future comparative study with a larger sample size. In the current study, the total vaginal length was well preserved by our technique which may be important for sexual function. The MT was associated with longer postoperative vaginal length, compared to the ST which can be attributed to a better cuff healing achieved by cold colpotomy that prevents the loss of the vaginal tissue demarcated by thermal damage. In the literature, there are few studies investigating the effect of vaginal length on sexual function and showing a weak correlation measured by Female Sexual Function Index questionnaire [ 19 – 21 ]. However, the evaluation was usually done shortly after hysterectomy ( i.e. , three months). This may be a distressing factor negatively contributing on sexual function. Thus, assessment of the sexual function in the long-term may eliminate this factor. Of note, the effect of our technique on sexual function was not the scope of our study due to short-term evaluation and small sample size. It is evident in the literature that omitting a concomitant apical support procedure during hysterectomy increases the re-operation rates for pelvic organ prolapse in the future [ 9 ]. Despite this, apical support procedures are not performed in most of the cases without uterovaginal prolapse. Even in cases with uterovaginal prolapse, only half of them receive a concomitant apical support procedure [ 10 ]. Due to this underutilization, the AAGL recommends USL suspension at the time of TLH to prevent future vaginal vault prolapse [ 11 ]. In our technique, suspension and/or plication of USLs was a routine step, leading to concomitant support of vaginal apex to prevent future vaginal vault prolapse. The procedure could be safely accomplished, while the margins of USLs and adjacent structures such as ureters were still prominent and pelvic anatomy was not altered. The number of suture loops depended on the prominent length of USLs (usually 1 to 3 bites). Thus, at least with only one bite, USL suspension was possible, while USL plication could be also performed with two or three bites. In the present study, the total operative time for colpotomy, extraction of uterus, and vaginal cuff closure were not significantly different between the groups, although the MT was associated with shorter total operative time compared to the ST. When the videos of the procedures were revisited, we found that the time loss leading to this difference was mostly related to checks for reassuring the safe margins to the bladder or demarcation line of thermal damage and haemostasis control for small bleedings in folded areas around the cuff and parametrium after cuff closure. Using the MT, placing the sutures before the pelvic anatomy was altered, slight retraction of both suture ends preventing unwanted bleedings during the colpotomy and cold colpotomy was probably eliminating the need for further checks, thereby, shortening the total surgical time. One bladder injury was reported in each group which is consistent with the literature [ 22 ]. Both injuries occurred in patients with prior pelvic surgery. The rate of bladder injury ranges from 0.2 to 1.8% in the literature and is mostly associated with previous laparotomy [ 22 ]. In contrast to prior study [ 14 ], unintentional cutting of the suture line during the cold colpotomy which increases the operative time did not occur in this study. This probably was due to experience gained by the increased number of cases. Also, a limiting factor for the Bakay technique was the size of uterus, as it was indicated in the previous study [ 14 ]. Although there was no statistically significant difference between the groups in terms of uterine weight, we analysed the data to determine the largest uterus removed by ST and MT in our study. The results were 465 g and 510 g, respectively, indicating that gaining experience in this technique could overcome the limitations described in the previous study- to some extent- related to large uterine size due to inadequate visualization of the posterior area. In our study, there was no significant difference in terms of postoperative complication rates and patient satisfaction scores between the groups at three months after the operations. In both groups, the patients described their postoperative condition as “much better” compared to preoperative condition. Nonetheless, there are some limitations to this study. It is not possible to reach a conclusion related to the effects of the MT on pelvic organ prolapse with a short term (90 days) follow up. Long-term outcomes of the MT related to cuff healing and pelvic organ prolapse should be evaluated in future prospective studies with adequate sample sizes. Although the sample size of this study is adequate to test most of the operative data, larger studies are needed to evaluate all possible complications of the novel technique. Further multi-centre, large-scale studies involving multiple number of surgeons are warranted to test the applicability and adoption of the technique in the surgical practice. Conclusion In conclusion, the MT can be safely utilized in most of the cases requiring TLH with certain advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff and routine concomitant apical support, even in some cases with a large uterus or history of pelvic surgery. Abbreviations TLH: Total laparoscopic hysterectomy USL: Uterosacral ligament MT: Modified Bakay technique ST: Standard technique PGI-I: Patient Global Impression of Improvement Declarations Acknowledgments We are thankful to Yazgülü Bozkurt and Dilek Sabancı (operating room nurses of Egemed Hospital) for her valuable support and contribution to this study by helping to coordinate the patient relations. Authors’ contributions ÜK contributed to design, data collection and processing, data interpretation, writing the manuscript, editing the manuscript. KB contributed to design, data collection and processing, data interpretation, editing the manuscript. All authors read and approved the final manuscript. Funding This study received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors. Availability of data and materials The data that support the findings of this study are available at Ondokuz Mayıs University and Egemed Hospitals database, which are not publicly available. Data are available from the authors upon reasonable request and with permission of the Ondokuz Mayıs University and Egemed Hospitals. Declarations The authors herein certify that they have no commercial, proprietary, or financial interest in the products or companies described in the manuscript. The authors did not receive grants or a consultant honorarium to conduct the study, write the manuscript, or otherwise assist in the development of the afore mentioned manuscript. All the participants gave consent for the publication of all the data related to study. The study was conducted in accordance with the principles of the Declaration of Helsinki. Ethics approval and consent to participate This study was approved by the Ondokuz Mayıs University Science and Ethics Committee with the Application Date: 23.02.2018 and Approval No: OMU KAEK 2018/22. All patients provided a written informed consent. The study was conducted in accordance with the principles of the Declaration of Helsinki. Competing interests The authors declare that they have no competing interests References AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL Position Statement: Route of Hysterectomy to Treat Benign Uterine Disease. J Minim Invasive Gynecol. 2011;18(1):1–3. Englund M, Robson S. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. J Minim Invasive Gynecol. 2007 Nov-Dec;14(6):724–8. Hwang JH, Lee JK, Lee NW, Lee KW. Vaginal cuff closure: a comparison between the vaginal route and laparoscopic suture in patients undergoing total laparoscopic hysterectomy. Gynecol Obstet Invest. 2011;71:163–169. Smith K, Caceres A. Vaginal cuff closure in minimally invasive hysterectomy: a review of training, techniques, and materials. Cureus . 2017;9:1–17. Mühlfay G, Horváth KU, Mocan SL, Budu VA, Ilyes IA, Doroş CI, et al. A study on the type of lesions achieved by three electrosurgical methods and their way of healing. Rom J Morphol Embryol. 2015;56(4):1383–1388. DeLancey J. Anatomy and Biomechanics of Genital Prolapse. Clinical Obstetrics and Gynecology. 1993; 36:897–909. Lowder JL, Meister M, Ghetti C, Li W, WingerDG, Shepherd JP. Reestablishing apical support at time of hysterectomy not performed for prolapse. American Urogynecologic Society Pelvic Floor Disorder Week 2015. Seattle, Washington: Female Pelv Med and Reconstr Surg; 2015. Kantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. International Urogynecology Journal. 2015; 26:207–12. Eilber KS, Alperin M, Khan A, Wu N, Pashos CL, Clemens JQ, Anger JT. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol. 2013;122:981–7. Ross WT, Meister MR, Shepherd JP, Olsen MA, Lowder JL. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol. 2017 Oct;217(4):436 .e1-436.e8 . AAGL. AAGL Practice Report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy. J Minim Invasive Gynecol. 2014; 21:715–22. Hill AM, Davis KM, Clark-Donat L, Hammons LM, Azodi M, Silasi DA. The effect of vertical versus horizontal vaginal cuff closure on vaginal length after laparoscopic hysterectomy. J Minim Invasive Gynecol. 2017;24:108–113. Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: Risk factors and management. Am J Obstet Gynecol. 2012 April; 206(4): 284–288. doi: 10.1016/j.ajog.2011.08.026 Bakay K. Introduction of a Novel Modification in Laparoscopic Hysterectomy: The Bakay Technique. J Minim Invasive Gynecol. 2018;25(5):916–919. doi: 10.1016/j.jmig.2018.03.013 . Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240: 205–213. Schulz KF, Altman DG, Moher D. Group C. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Open Med. 2010;4:e60–e68. Hefermehl LJ, Largo RA, Hermanns T, Poyet C, Sulser T, Eberli D Lateral temperature spread of monopolar, bipolar and ultrasonic instruments for robot-assisted laparoscopic surgery. BJU Int 2014;114:245–252. Nezhat C, Kennedy Burns M, Wood M, Nezhat C, Nezhat A, Nezhat F. Vaginal Cuff Dehiscence and Evisceration: A Review. Obstet Gynecol. 2018;132(4):972–985. doi: 10.1097/AOG.0000000000002852 Schimpf MO, Harvie HS, Omotosho TB, et al. Does vaginal size impact sexual activity and function? Int Urogynecol J. 2010;21: 447–452. Bastu E, Yasa C, Dural O, Ozgor BY, Yilmaz G, Gungor Ugurlucan F, Buyru F, Banerjee S. Comparison of 2 Methods of Vaginal Cuff Closure at Laparoscopic Hysterectomy and Their Effect on Female Sexual Function and Vaginal Length: A Randomized Clinical Study. J Minim Invasive Gynecol. 2016 Sep-Oct;23(6):986–93. doi: 10.1016/j.jmig.2016.07.007 . Epub 2016 Jul 15. PMID: 27426680. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191–208. Lafay Pillet MC, Leonard F, Chopin N, et al. Incidence and risk factors of bladder injuries during laparoscopic hysterectomy indicated for benign uterine pathologies: a 14.5 years experience in a continuous series of 1501 procedures. Hum Reprod. 2009;24:842–849. Additional Declarations No competing interests reported. Supplementary Files video1.avi Video 1. Video showing the modified Bakay procedure of a case with no history of abdominal operations. video2.mp4 Video 2. Video showing the modified Bakay procedure of a case with a history of caesarean section. Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2022 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Major revision 17 Nov, 2021 Reviews received at journal 11 Nov, 2021 Reviews received at journal 03 Nov, 2021 Reviewers agreed at journal 03 Nov, 2021 Reviewers agreed at journal 01 Nov, 2021 Reviewers invited by journal 28 Oct, 2021 Editor assigned by journal 22 Oct, 2021 Editor invited by journal 22 Oct, 2021 Submission checks completed at journal 22 Oct, 2021 First submitted to journal 24 Aug, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-841945","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":58483350,"identity":"f437daa3-5e03-46d5-94ba-de48a93be137","order_by":0,"name":"Üzeyir Kalkan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3RIQsCMRTA8beiRS5PhPMr7LD6YXYYrnhiEoOglqXDfEPwM3jf4MZAy9RqMNwhmAxajKJDg5bNaNi/vPHgBw8G4HL9YzVAYgLgY/2a6E1uJ6BJ65O8po2E6c+EKFmIdHSIeBrniDPwvT2tHocmsmFELFeneI57FGUMWvU9RVNlIjsgoqjIeIG7BJUMwqUmpsvIrnoRxV1G/puM7WSTEJExSRuaPA+jxEbqSvUFn8mAJ2ci0i0OuCqn3EQ8FWVlcpNNvO4GZTJoN711J7+ayFc5AH4Oy0+6XC6Xy94Dg1lbYgY9QRwAAAAASUVORK5CYII=","orcid":"","institution":"Koç University Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Üzeyir","middleName":"","lastName":"Kalkan","suffix":""},{"id":58483351,"identity":"5161eb04-4b52-4da6-bff3-cd864e42a983","order_by":1,"name":"Kadir Bakay","email":"","orcid":"","institution":"Ondokuz Mayis University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kadir","middleName":"","lastName":"Bakay","suffix":""}],"badges":[],"createdAt":"2021-08-24 06:59:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-841945/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-841945/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-021-01591-z","type":"published","date":"2022-01-08T04:45:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":14873949,"identity":"097800c2-2350-4bec-94c6-0f1dbedcd1f5","added_by":"auto","created_at":"2021-10-25 15:39:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":643647,"visible":true,"origin":"","legend":"The steps of the modified Bakay technique are described. First suture is placed on the right USL (A) then helically proceeded for suspension/plication (B). The suture continued circumferentially in the counterclockwise direction on the line between the cervicovaginal junction and the bladder (C,D,E) in a full-thickness purse string fashion. This suture symmetrically ended in the left USL, across the point of the start (F,G,H). Colpotomy is performed circumferentially using laparoscopic cold scissors and/or knife (I), maintaining a safe distance from the suture line, paying attention not to cut the suture. The detached uterus is removed vaginally (J) and both ends of the prior suture line are knotted securely (K,L).","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-841945/v1/ef2b0e856718c21d9092ea6c.jpg"},{"id":14874253,"identity":"f8124097-27b5-4af3-9aa2-34bdbf655bf1","added_by":"auto","created_at":"2021-10-25 15:42:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34287,"visible":true,"origin":"","legend":"The CONSORT study flow chart ","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-841945/v1/3b3dea1f4ea105b761fac426.png"},{"id":17121081,"identity":"2ec95524-78b5-4f64-8130-43483e7e02f1","added_by":"auto","created_at":"2022-01-08 04:45:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":778237,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-841945/v1/7fbacb5b-b464-4d25-ba0e-a1c38898dbd8.pdf"},{"id":14873951,"identity":"ddb886b9-29da-4ace-85c7-c4931e0f0076","added_by":"auto","created_at":"2021-10-25 15:39:19","extension":"avi","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":103780606,"visible":true,"origin":"","legend":"Video 1. Video showing the modified Bakay procedure of a case with no history of abdominal operations.","description":"","filename":"video1.avi","url":"https://assets-eu.researchsquare.com/files/rs-841945/v1/956f8cee625b8002049736b1.avi"},{"id":14873952,"identity":"4aefcef6-390f-4dcb-8654-5a072e8ec97b","added_by":"auto","created_at":"2021-10-25 15:39:20","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":125361838,"visible":true,"origin":"","legend":"Video 2. Video showing the modified Bakay procedure of a case with a history of caesarean section.","description":"","filename":"video2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-841945/v1/73a2ea3220ff1678831edbf7.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA Multimodal Concept for Vaginal Cuff Closure by Modification of the Bakay Technique in Total Laparoscopic Hysterectomy: A Randomized Clinical Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlthough the benefits of laparoscopy including less postoperative discomfort, short recovery time, and improved patient outcomes are well documented in the literature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], there are many factors still limiting the wide acceptance and implementation of the technique for hysterectomy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The most challenging steps of total laparoscopic hysterectomy (TLH) are colpotomy and cuff closure. The basis for minimizing the rate of severe haemorrhage and ureteral injuries, the most serious events related to these steps, is meticulous dissection providing a clear operative field and the skill and experience of the surgeon. In TLH, the altered anatomy after the removal of the uterus may cause the retraction of vagina and shifting of neighbouring structures such as bladder and/or bowel to this pouch, thereby, leading to obstruction of the operative field for vaginal cuff closure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eElectrosurgical colpotomy is usually the preferred technique in TLH. However, this may cause more extensive tissue necrosis and devascularization, leading to a thicker inflammatory infiltrate and late tissue healing (\u003cem\u003ei.e.\u003c/em\u003e, per secundam intentionem). This prolonged inflammatory phase may increase the risk of cuff cellulitis, dehiscence, granulation and secondary haemorrhages. Therefore, it is of utmost importance to put the sutures beyond the demarcation line of this thermal damage to for tissue integrity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe apical uterovaginal support is compromised by total hysterectomies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Unless re-attachment of the uterosacral ligament (USL) complex to vaginal cuff is performed, Level I support is lost, potentially leading to future vaginal vault prolapse [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A concomitant procedure for apical support performed during hysterectomy lowers the re-operation rates for pelvic organ prolapse in the future [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite this, apical support procedures appear to be underutilized: they are performed in only 3% and 55% of cases without and with a diagnosis of uterovaginal prolapse [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The American Association of Gynecologic Laparoscopists (AAGL) also recommends USL suspension at the time of TLH to prevent future vaginal vault prolapse [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, various methods of cuff closure in TLH have been described [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Bakay [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] published his novel colpotomy and cuff closure technique for TLH in 2018.This study was the first to describe placing a single continuous running purse-string suture facilitating the cuff closure before colpotomy. The main advantage of the technique involved retrieving the safe suture margins required for vaginal cuff closure before the pelvic anatomy was altered by the removal of the uterus. In addition to this advantage, we modified the technique to achieve a better cuff healing and standardized apical support and the modified Bakay technique (MT) proposes: \u003cem\u003ei)\u003c/em\u003e placing a single continuous running purse-string suture for vaginal cuff closure before the pelvic anatomy is altered by the colpotomy and removal of the uterus; \u003cem\u003eii)\u003c/em\u003e suspension/plication of USLs (as a well-defined, efficient, concomitant apical support procedure to prevent future vaginal vault prolapse) routinely in each case before colpotomy while the margins of these ligaments and adjacent structures such as ureters are still prominent and pelvic anatomy is not altered; and \u003cem\u003eiii)\u003c/em\u003e using cold-knife colpotomy instead of electrosurgical colpotomy to support the primary healing of the vaginal cuff. In the present study, we aimed to compare the surgical and clinical outcomes of the MT to standard technique (ST) in patients undergoing TLH.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003ch2\u003eStudy design and study population\u003c/h2\u003e\n\u003cp\u003eThis two centre, randomized clinical study was conducted at Departments of Obstetrics and Gynaecology of two tertiary care centres between November 2018 and September 2020. The patients who were scheduled to undergo TLH for benign diseases were screened. Pelvic examination, transvaginal ultrasound, Pap-smear and endometrial biopsy, urine analysis, blood analysis including complete blood count, prothrombin time and partial thromboplastin time, and electrocardiography were performed preoperatively. Prior to study, all patients were informed about the nature of the study. A written informed consent was obtained from each patient. The study protocol was approved by the institutional Science and Ethics Committee (Application Date: 23.02.2018 and Approval No: OMU KAEK 2018/22). The study was conducted in accordance with the principles of the Declaration of Helsinki. ClinicalTrials.gov registration number is NCT05080114\u0026nbsp;and the first posted date was 15/10/2021.\u003c/p\u003e\n\u003cp\u003eThe patients who fulfilled the inclusion criteria were allocated into two groups by a computer-based randomization programme as ST group (n=80) and MT group (n=80).\u0026nbsp;The main indications for surgery were symptomatic uterine fibromatosis, chronic pelvic pain, simple or complex endometrial hyperplasia, menorrhagia/adenomyosis, or benign adnexal masses. Patients with anaesthetic contraindications to laparoscopy, premalignant or malignant genital disease, prior pelvic and/or abdominal radiotherapy, large adnexal masses; large fibroids obscuring the visualization of the cervicovaginal junction; suspicion of malignancy; and pelvic organ prolapse Stage \u0026gt;2 were excluded. All procedures were performed by two gynaecologic surgeons who are both skilled and experienced in laparoscopic surgery.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDefinitions and outcome measures\u003c/h2\u003e\n\u003cp\u003eThe operative time was defined as the time interval between the placement and removal of the primary trocar. As the sequence of colpotomy, removal of uterus and cuff suturing steps are different in each technique, operative times of colpotomy, extraction of uterus, and vaginal cuff closure steps were each added for comparison. Blood loss was measured by examining the amount of blood aspirated during the procedure.\u003c/p\u003e\n\u003cp\u003ePreoperative vaginal length measurements were taken during the first preoperative vaginal examination in the relaxed dorsal lithotomy position by wooden tongue depressors scaled before. The distance from posterior vaginal vault to hymen was recorded as the vaginal length. Postoperative vaginal length measurements and Patient Global Impression of Improvement (PGI-I) questionnaire was performed on Day 90 postoperatively. The PGI-I questionnaire consisting of the question \u0026ldquo;How is your postoperative condition now, compared to how it was before you had the surgery?\u0026rdquo; was filled by the patient in the waiting room before the pelvic examination on Day 90. The response for the question ranges from 1 to 7 with lower scores indicating a greater level of satisfaction.\u003c/p\u003e\n\u003cp\u003ePostoperative complications were recorded during follow-up visits on Day 7, 30, and 90. Classification of complications was made based on the standardized Clavien-Dindo reporting system [15].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSurgical procedure\u003c/h2\u003e\n\u003cp\u003eAll operations were performed under general anaesthesia with nasogastric intubation and a bladder catheter in place. Cefazolin 2 g was administered to all patients for prophylaxis 30 min prior to surgery. Operations were performed with a 10-mm laparoscope (Karl Storz, Germany) through the trocar placed usually in the umbilicus. Two lateral 5-mm trocars and one midline 10-mm trocar were used. The placement of trocars varied according to the uterine size. Haemostasis was usually performed using bipolar forceps (Karl Storz Robi, Germany), whereas dissection was performed using the LigaSure\u0026trade; (Covidien, Medtronic, USA)\u0026nbsp;Maryland jaw laparoscopic sealer/divider, bipolar forceps and scissors. In both groups, all the steps of the TLH leading to colpotomy were performed according to standard protocol. However, the sequence and technique of the remaining steps in the MT group were different as follows:\u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eA 0 Monocryl\u0026trade; violet (poliglecaprone 25) or a 0 PDS II (polydioxanone) suture with a 36-mm needle (Ethicon Inc., NJ, USA) through the 10-mm midline trocar was placed first on the right USL, proximal to the ischial spine, usually 1 to 3 cm away from its uterine insertion, then helically proceeded by 1 to 3 bite(s) (depending on the length of the ligament) for suspension/plication. The suture continued circumferentially in the counterclockwise direction on the line between the cervicovaginal junction and the bladder in a full-thickness purse string fashion, paying attention not to get closer than 1 cm to the bladder. This suture symmetrically ended in the left USL, across the point of the start, again by completing the last bite(s) helically for suspension/plication, forming nearly an Ohm sign (\u0026Omega;). Once accomplished, suture ends were pulled outside by the assistant surgeon via the10-mm port for retraction and further extracorporeal knot tying; or left inside and grasped by an instrument for further intracorporeal knot tying. This gentle retraction was also intended to slightly pull the suture ends in case of a bleeding that might occur during the cold scissor/knife colpotomy.\u003c/li\u003e\n \u003cli\u003eColpotomy was performed circumferentially using laparoscopic cold scissors and/or knife,\u0026nbsp;maintaining a safe distance from the suture line, paying attention not to cut the suture.\u003c/li\u003e\n \u003cli\u003eThe detached uterus was, then, removed vaginally and both ends of the prior suture line were knotted securely.\u0026nbsp;The steps are summarized in Figure 1. The closed vaginal cuff was manually examined for any defects under endoscopic visualization. No additional sutures were used.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe first video (Video 1) shows the procedure of a case with no history of abdominal operations. The second video (Video 2) shows a case with a history of caesarean section.\u003c/p\u003e\n\u003cp\u003eAll patients were informed to refrain from sexual intercourse for at least 60 days after the operation.\u003c/p\u003e\n\u003ch2\u003eMain outcomes\u003c/h2\u003e\n\u003cp\u003eDemographic and clinical data, history of previous surgery, and intra- and postoperative findings were recorded. Operative time (time interval between the placement and removal of primary trocar); total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps; uterine weight (measured before immersion in formaldehyde); blood loss (estimate of the fluid aspirated during the procedure); and length of hospital stay were also noted. The complications were recorded by the clinical evaluation of the patients on Day 7, 30, and 90 postoperatively. Pre- and postoperative vaginal length and patient satisfaction were evaluated.\u003c/p\u003e\n\u003ch2\u003eStatistical analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eStatistical analysis was performed using the SPSS version 23.0 software (IBM Corp., Armonk, NY, USA). Descriptive data were presented in mean \u0026plusmn; standard deviation (SD), median (min-max) or number and frequency, where applicable. Normal distribution of variables was tested using the Kolmogorov-Smirnov test. Independent samples \u003cem\u003et\u003c/em\u003e-test was used to compare normally distributed data, while the Mann-Whitney U was used to compare data that did not show normal distribution. The chi-square test was used for the comparison of categorical data. A p value of \u0026lt;0.05 was considered statistically significant. \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 174 patients scheduled to undergo TLH for benign diseases were screened. Eleven patients refused to participate and three patients were excluded due to anaesthetic contraindications to laparoscopy. Finally, 160 patients who met the inclusion criteria were allocated into two groups by a computer-based randomization programme as ST group and MT group. Of 80 patients allocated for ST group, 10 patients were dropped out (n=7 not attending to the visit on Day 90, n=3 having a diagnosis of deep infiltrating endometriosis requiring discoid vaginal wall resection during TLH). Among 80 patients allocated for MT group, only two patients were dropped out, as they did not attend to visit on Day 90. Finally, a total of 70 patients in the ST group and 78 patients in the MT group were included in the analysis. The CONSORT study flow chart [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] is shown in Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eAge, body mass index (BMI), parity, menopausal status, history of pelvic surgery, and indications for laparoscopic surgeries did not differ significantly between the groups (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The median age for ST group and MT group was 46 (range, 35 to 56) and 47 (range, 36 to 59) years, respectively. The median BMI for ST group and MT group was 28.1 (range, 19,2 to 40,6) and 26.8 (range, 19,2 to 42,1) kg/m\u003csup\u003e2\u003c/sup\u003e respectively. For both groups, the median parity was 2 (range, 0 to 5). In ST group, 35 (50%) patients and, in MT group, 45 (57.7%) patients had history of pelvic surgery. In ST group 21 (30%) patients and, in MT group, 27 (34.6%) patients were in the postmenopausal period. The ST was performed due to indications of abnormal uterine bleeding and adenomyosis in 21 (30%), myoma in 31 (44.3%), endometrial polyps in five (7.1%), chronic pelvic pain in three (4.3%), adnexal masses in six (8.6%), and simple or complex endometrial hyperplasia in four (5.7%) women. The MT was performed due to abnormal uterine bleeding and adenomyosis in 17 (21.8%), myoma in 34 (43.6%), endometrial polyps in seven (9%), chronic pelvic pain in five (6.4%), adnexal masses in 11 (14.1%), and simple or complex endometrial hyperplasia in four (5.1%) women. There were no conversions to laparotomy in either group.\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic data of the patients and indications for surgery.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandard technique group\u003c/p\u003e\n \u003cp\u003e(n=70)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModified Bakay technique\u003c/p\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003cp\u003e(n=78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n=148)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest statistics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (yr)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (35 - 56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (36 - 59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (36 - 59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2673\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,826\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,1 (19,2-40,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26,8 (19,2-42,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27,4 (19,2-42,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2651,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,763\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0 - 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0 - 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0 - 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2463\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,291\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of pelvic surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (57,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (54,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;2=0,879\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,348\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (42,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (45,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndications for hysterectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003e\u0026chi;2=2,438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003e0,786\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMenorrhagia and Adenomyosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (21,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (25,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMyoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (44,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (43,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (43,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndometrial polyp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (8,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdnexal mass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (8,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (14,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (11,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic pelvic pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (4,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (6,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (5,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSimple or complex hyperplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (5,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMenopausal status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026chi;2=0,359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0,549\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePremenopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (65,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (67,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostmenopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (34,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (32,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eU: Mann Whitney U test,\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({ \\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e: Chi-square test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eOperative data and outcome measures are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The median operative time for ST group was 59 (range, 50 to 75) min and 55.5 (range, 34 to 80) min for the MT group. The operative time was significantly shorter in the MT group (p=0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure was equal in both groups (9 min for both groups). In both groups, the median length of hospital stay was 2 (range, 1 to 4) days. The median intraoperative blood loss was 90 mL in the ST group and 80 mL in the MT group, indicating no statistically significant difference (p=0.456). The mean uterine weight for the ST group and MT group was 258.6\u0026plusmn;88.6 g and 232.9\u0026plusmn;102.5 g, respectively, indicating no statistically significant difference (p=0.107). The median preoperative vaginal length was not significantly different between the groups (p=0.502). However, the median postoperative vaginal length on Day 90 was significantly higher in the MT group compared to the ST group (8 [6 to 9.5] cm \u003cem\u003evs.\u003c/em\u003e 7.5 [5.5 to 9] cm, respectively; p= 0.001)). The median patient satisfaction as measured by PGI-I scale on Day 90 was 2 (range, 1 to 5) in both groups, indicating no statistically significant difference (p=0.636).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSurgical data and outcome measures.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandard technique group\u003c/p\u003e\n \u003cp\u003e(n=70)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModified Bakay technique\u003c/p\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003cp\u003e(n=78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n=148)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003cp\u003estatistics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperative time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (50 - 75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55,5 (34 - 80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (34 - 80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=1885,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative blood loss (ml)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (60 - 150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (60 - 180)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (60 - 180)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2536,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,456\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLenght of hospital stay (d)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1 - 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1 - 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1 - 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,949\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUterine weight (g)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e258,6 \u0026plusmn; 88,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e232,9 \u0026plusmn; 102,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e245 \u0026plusmn; 96,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003et=1,623\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal operative time for colpotomy, extraction of uterus, and vaginal cuff closure (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (6 - 11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (6 - 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (6 - 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2533,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative and postoperative complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (8,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (6,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;2=1,442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64 (91,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (96,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139 (93,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative vaginal length (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6,5 - 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,5 (6,5 - 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6,5 - 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2559\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,502\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative vaginal length (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,5 (5,5 - 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6 - 9,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,5 (5,5 - 9,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=1854,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient satisfaction by PGI-I scale on day 90 postoperatively\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1 - 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1 - 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1 - 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU=2614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,636\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eU: Mann Whitney U test, t: Independent samples t test; \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e: Chi-square test; \u003csup\u003e*\u003c/sup\u003e: p value\u0026lt;.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe complication rates were not significantly different between the groups (p=0.230). There was one bladder injury, one urinary tract infection and one trocar site infection in each group. Bladder injuries were detected and repaired intraoperatively. The trocar site and urinary infections were successfully treated with proper antibiotherapy. In the ST group, additionally, one patient had fever (\u0026gt;38\u003csup\u003e\u0026deg;\u003c/sup\u003eC) who was successfully treated with antibiotic and antipyretics, one patient had ileus who was successfully treated with conservative measures such as oral restriction, antiemetics, and electrolyte solution infusions, and one patient had cuff granulation who was diagnosed on Day 60 and treated by electrocoagulation under local anaesthesia. Complications are listed in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIntraoperative and postoperative complications.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClavien-Dindo classification\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandard technique\u003c/p\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003cp\u003e(n=70)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModified Bakay technique\u003c/p\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003cp\u003e(n=78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n=148)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative and postoperative complications (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBladder injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade 3b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary tract infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrocar site infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCuff granulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade 3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVarious techniques for vaginal cuff incision and closure in TLH have been described in the literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this study, the Bakay technique [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] was modified to achieve a routine concomitant effective apical support to prevent future vaginal vault prolapse, and primary healing of the vaginal cuff by using cold-knife colpotomy, instead of electrosurgical colpotomy, in addition to the former objective of the technique that was vaginal cuff closure with safe suture margins before the pelvic anatomy was altered by the removal of the uterus. The clinical and surgical outcomes of the MT showed successful results compared to ST.\u003c/p\u003e \u003cp\u003eColpotomy and cuff closure steps are technically the most difficult and prolonged parts of TLH. Additionally, the most frequent complications of TLH, which are ureteral injury and bleeding, mostly occur in these steps. One of the main advantages of the MT involves placing the sutures before the pelvic anatomy is altered by the colpotomy/removal of the uterus providing to maintain the required suture margins with a safe distance from the bladder, ureters, and bowels in a shorter total operating time.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, there is no study specifically comparing cold-knife colpotomy with electrosurgical colpotomy at TLH. During the colpotomy, monopolar current when applied at 60 W for 1 s exhibits a mean critical spread of 3.5 mm; however, the spread exceeds 20 mm when applied for \u0026ge;2 s [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Thus, a more prolonged continuous current may increase the extent of collateral damage. Current recommendations for colpotomy and cuff closure in TLH are to minimize lateral thermal spread to maintain tissue integrity and to place sutures well beyond the border of thermal damage to prevent vaginal cuff dehiscence and evisceration [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In MT, using cold-knife colpotomy, instead of electrosurgical colpotomy, we intended to eliminate extensive tissue necrosis and devascularization leading to a thicker inflammatory infiltrate and late tissue healing (per secundam intentionem). As a point of good practice, this may contribute to prevent cuff cellulitis, cuff dehiscence, and secondary cuff haemorrhages by supporting the primary healing of the vaginal cuff. Also, our technique may tolerate the smaller purchases on vaginal cuff being sutured caused by the laparoscopic magnification of the surgical field. In this study, there was no significant difference in the postoperative complication rates between the groups, although the sample size is too small to specifically compare the rate of complications such as cuff cellulitis, dehiscence, granulation, and secondary cuff haemorrhages. This may be the subject of a future comparative study with a larger sample size.\u003c/p\u003e \u003cp\u003eIn the current study, the total vaginal length was well preserved by our technique which may be important for sexual function. The MT was associated with longer postoperative vaginal length, compared to the ST which can be attributed to a better cuff healing achieved by cold colpotomy that prevents the loss of the vaginal tissue demarcated by thermal damage. In the literature, there are few studies investigating the effect of vaginal length on sexual function and showing a weak correlation measured by Female Sexual Function Index questionnaire [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, the evaluation was usually done shortly after hysterectomy (\u003cem\u003ei.e.\u003c/em\u003e, three months). This may be a distressing factor negatively contributing on sexual function. Thus, assessment of the sexual function in the long-term may eliminate this factor. Of note, the effect of our technique on sexual function was not the scope of our study due to short-term evaluation and small sample size.\u003c/p\u003e \u003cp\u003eIt is evident in the literature that omitting a concomitant apical support procedure during hysterectomy increases the re-operation rates for pelvic organ prolapse in the future [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite this, apical support procedures are not performed in most of the cases without uterovaginal prolapse. Even in cases with uterovaginal prolapse, only half of them receive a concomitant apical support procedure [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Due to this underutilization, the AAGL recommends USL suspension at the time of TLH to prevent future vaginal vault prolapse [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our technique, suspension and/or plication of USLs was a routine step, leading to concomitant support of vaginal apex to prevent future vaginal vault prolapse. The procedure could be safely accomplished, while the margins of USLs and adjacent structures such as ureters were still prominent and pelvic anatomy was not altered. The number of suture loops depended on the prominent length of USLs (usually 1 to 3 bites). Thus, at least with only one bite, USL suspension was possible, while USL plication could be also performed with two or three bites.\u003c/p\u003e \u003cp\u003eIn the present study, the total operative time for colpotomy, extraction of uterus, and vaginal cuff closure were not significantly different between the groups, although the MT was associated with shorter total operative time compared to the ST. When the videos of the procedures were revisited, we found that the time loss leading to this difference was mostly related to checks for reassuring the safe margins to the bladder or demarcation line of thermal damage and haemostasis control for small bleedings in folded areas around the cuff and parametrium after cuff closure. Using the MT, placing the sutures before the pelvic anatomy was altered, slight retraction of both suture ends preventing unwanted bleedings during the colpotomy and cold colpotomy was probably eliminating the need for further checks, thereby, shortening the total surgical time.\u003c/p\u003e \u003cp\u003eOne bladder injury was reported in each group which is consistent with the literature [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Both injuries occurred in patients with prior pelvic surgery. The rate of bladder injury ranges from 0.2 to 1.8% in the literature and is mostly associated with previous laparotomy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In contrast to prior study [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], unintentional cutting of the suture line during the cold colpotomy which increases the operative time did not occur in this study. This probably was due to experience gained by the increased number of cases. Also, a limiting factor for the Bakay technique was the size of uterus, as it was indicated in the previous study [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although there was no statistically significant difference between the groups in terms of uterine weight, we analysed the data to determine the largest uterus removed by ST and MT in our study. The results were 465 g and 510 g, respectively, indicating that gaining experience in this technique could overcome the limitations described in the previous study- to some extent- related to large uterine size due to inadequate visualization of the posterior area.\u003c/p\u003e \u003cp\u003eIn our study, there was no significant difference in terms of postoperative complication rates and patient satisfaction scores between the groups at three months after the operations. In both groups, the patients described their postoperative condition as \u0026ldquo;much better\u0026rdquo; compared to preoperative condition.\u003c/p\u003e \u003cp\u003eNonetheless, there are some limitations to this study. It is not possible to reach a conclusion related to the effects of the MT on pelvic organ prolapse with a short term (90 days) follow up. Long-term outcomes of the MT related to cuff healing and pelvic organ prolapse should be evaluated in future prospective studies with adequate sample sizes. Although the sample size of this study is adequate to test most of the operative data, larger studies are needed to evaluate all possible complications of the novel technique. Further multi-centre, large-scale studies involving multiple number of surgeons are warranted to test the applicability and adoption of the technique in the surgical practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the MT can be safely utilized in most of the cases requiring TLH with certain advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff and routine concomitant apical support, even in some cases with a large uterus or history of pelvic surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTLH: Total laparoscopic hysterectomy\u003c/p\u003e\n\u003cp\u003eUSL: Uterosacral ligament\u003c/p\u003e\n\u003cp\u003eMT: Modified Bakay technique\u003c/p\u003e\n\u003cp\u003eST: Standard technique\u003c/p\u003e\n\u003cp\u003ePGI-I: Patient Global Impression of Improvement\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eWe are thankful to Yazg\u0026uuml;l\u0026uuml; Bozkurt and Dilek Sabancı (operating room nurses of Egemed Hospital) for her valuable support and contribution to this study by helping to coordinate the patient relations. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003e\u0026Uuml;K contributed to design, data collection and processing, data interpretation, writing the manuscript, editing the manuscript. KB contributed to design, data collection and processing, data interpretation, editing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available at Ondokuz Mayıs University and Egemed Hospitals database, which are not publicly available. Data are available from the authors upon reasonable request and with permission of the Ondokuz Mayıs University and Egemed Hospitals.\u003c/p\u003e\n\u003ch2\u003eDeclarations\u003c/h2\u003e\n\u003cp\u003eThe authors herein certify that they have no commercial, proprietary, or financial interest in the products or companies described in the manuscript. The authors did not receive grants or a consultant honorarium to conduct the study, write the manuscript, or otherwise assist in the development of the afore mentioned manuscript. All the\u0026nbsp;participants gave consent for the publication of all the data related to study. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Ondokuz Mayıs University Science and Ethics Committee with the Application Date: 23.02.2018 and Approval No: OMU KAEK 2018/22. All patients provided a written informed consent. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL Position Statement: Route of Hysterectomy to Treat Benign Uterine Disease. J Minim Invasive Gynecol. 2011;18(1):1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnglund M, Robson S. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. J Minim Invasive Gynecol. 2007 Nov-Dec;14(6):724\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang JH, Lee JK, Lee NW, Lee KW. Vaginal cuff closure: a comparison between the vaginal route and laparoscopic suture in patients undergoing total laparoscopic hysterectomy. Gynecol Obstet Invest. 2011;71:163\u0026ndash;169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith K, Caceres A. Vaginal cuff closure in minimally invasive hysterectomy: a review of training, techniques, and materials. \u003cem\u003eCureus\u003c/em\u003e. 2017;9:1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026uuml;hlfay G, Horv\u0026aacute;th KU, Mocan SL, Budu VA, Ilyes IA, Doroş CI, et al. A study on the type of lesions achieved by three electrosurgical methods and their way of healing. Rom J Morphol Embryol. 2015;56(4):1383\u0026ndash;1388.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeLancey J. Anatomy and Biomechanics of Genital Prolapse. Clinical Obstetrics and Gynecology. 1993; 36:897\u0026ndash;909.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLowder JL, Meister M, Ghetti C, Li W, WingerDG, Shepherd JP. Reestablishing apical support at time of hysterectomy not performed for prolapse. American Urogynecologic Society Pelvic Floor Disorder Week 2015. Seattle, Washington: Female Pelv Med and Reconstr Surg; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. International Urogynecology Journal. 2015; 26:207\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEilber KS, Alperin M, Khan A, Wu N, Pashos CL, Clemens JQ, Anger JT. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol. 2013;122:981\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoss WT, Meister MR, Shepherd JP, Olsen MA, Lowder JL. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol. 2017 Oct;217(4):436\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e1-436.e8\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAAGL. AAGL Practice Report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy. J Minim Invasive Gynecol. 2014; 21:715\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill AM, Davis KM, Clark-Donat L, Hammons LM, Azodi M, Silasi DA. The effect of vertical versus horizontal vaginal cuff closure on vaginal length after laparoscopic hysterectomy. J Minim Invasive Gynecol. 2017;24:108\u0026ndash;113.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: Risk factors and management. Am J Obstet Gynecol. 2012 April; 206(4): 284\u0026ndash;288. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2011.08.026\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakay K. Introduction of a Novel Modification in Laparoscopic Hysterectomy: The Bakay Technique. J Minim Invasive Gynecol. 2018;25(5):916\u0026ndash;919. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2018.03.013\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240: 205\u0026ndash;213.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchulz KF, Altman DG, Moher D. Group C. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Open Med. 2010;4:e60\u0026ndash;e68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHefermehl LJ, Largo RA, Hermanns T, Poyet C, Sulser T, Eberli D Lateral temperature spread of monopolar, bipolar and ultrasonic instruments for robot-assisted laparoscopic surgery. BJU Int 2014;114:245\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNezhat C, Kennedy Burns M, Wood M, Nezhat C, Nezhat A, Nezhat F. Vaginal Cuff Dehiscence and Evisceration: A Review. Obstet Gynecol. 2018;132(4):972\u0026ndash;985. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000002852\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchimpf MO, Harvie HS, Omotosho TB, et al. Does vaginal size impact sexual activity and function? Int Urogynecol J. 2010;21: 447\u0026ndash;452.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBastu E, Yasa C, Dural O, Ozgor BY, Yilmaz G, Gungor Ugurlucan F, Buyru F, Banerjee S. Comparison of 2 Methods of Vaginal Cuff Closure at Laparoscopic Hysterectomy and Their Effect on Female Sexual Function and Vaginal Length: A Randomized Clinical Study. J Minim Invasive Gynecol. 2016 Sep-Oct;23(6):986\u0026ndash;93. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2016.07.007\u003c/span\u003e\u003c/span\u003e. Epub 2016 Jul 15. PMID: 27426680.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafay Pillet MC, Leonard F, Chopin N, et al. Incidence and risk factors of bladder injuries during laparoscopic hysterectomy indicated for benign uterine pathologies: a 14.5 years experience in a continuous series of 1501 procedures. Hum Reprod. 2009;24:842\u0026ndash;849.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic cuff closure, Laparoscopic hysterectomy, Bakay technique, Cold colpotomy","lastPublishedDoi":"10.21203/rs.3.rs-841945/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-841945/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eSeventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (59 \u003cem\u003evs.\u003c/em\u003e 55.5 min, respectively; p=0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range, 6 to 12 in MT\u003cem\u003e vs.\u003c/em\u003e 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range, 1 to 4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST \u003cem\u003evs.\u003c/em\u003e 80 mL in MT; p=0.456). The mean uterine weight for the ST group and MT group was comparable (258.6±88.6 g \u003cem\u003evs.\u003c/em\u003e 232.9±102.5 g, respectively; p=0.107). The preoperative vaginal length was not significantly different between the groups (p=0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm \u003cem\u003evs.\u003c/em\u003e 7,5 cm, respectively; p= 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range, 1 to 5) in both groups (p=0.636). The complication rates were similar between the groups (p=0.230).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support.\u003c/p\u003e","manuscriptTitle":"A Multimodal Concept for Vaginal Cuff Closure by Modification of the Bakay Technique in Total Laparoscopic Hysterectomy: A Randomized Clinical Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-10-25 15:39:14","doi":"10.21203/rs.3.rs-841945/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-11-17T06:08:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-11-11T23:11:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-11-03T18:41:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5f2693a0-3853-4425-a820-75f38fefbd28","date":"2021-11-03T16:57:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f00c2ab8-82eb-4761-a073-6fa09f17a847","date":"2021-11-01T10:29:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-10-28T14:13:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-10-22T16:24:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-10-22T15:16:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-10-22T15:14:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2021-08-24T06:46:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6c26976-e967-4e5d-bfa3-91be1286ff29","owner":[],"postedDate":"October 25th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":8085658,"name":"Health Economics \u0026 Outcomes Research"},{"id":8085659,"name":"Health Policy"}],"tags":[],"updatedAt":"2022-01-08T04:45:05+00:00","versionOfRecord":{"articleIdentity":"rs-841945","link":"https://doi.org/10.1186/s12905-021-01591-z","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2022-01-08 04:45:05","publishedOnDateReadable":"January 8th, 2022"},"versionCreatedAt":"2021-10-25 15:39:14","video":"","vorDoi":"10.1186/s12905-021-01591-z","vorDoiUrl":"https://doi.org/10.1186/s12905-021-01591-z","workflowStages":[]},"version":"v1","identity":"rs-841945","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-841945","identity":"rs-841945","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}