Obstetrics and Gynecology Science最新文献

Vaginal hysterectomy remains the least invasive approach for benign gynecologic diseases, but has steadily declined due to limited surgical exposure during residency. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as an innovative technique that combines endoscopic advantages with those of the vaginal route. This review systematically evaluates the clinical outcomes, emerging technological advancements, and global feasibility of vNOTES hysterectomy with a particular focus on its potential to strategically reposition the vaginal route as the primary minimally invasive option in gynecologic surgery. A comprehensive literature review was performed to assess comparative studies, surgical variants, perioperative outcomes, and learning curves of vNOTES, including advanced forms of total NOTES hysterectomy (TNH), isobaric vNOTES (iNH), and robotic vNOTES (RvNH). vNOTES hysterectomy consistently demonstrates favorable perioperative outcomes, such as reduced operative time, lower blood loss, decreased postoperative pain, and shorter hospital stay, compared with laparoscopic hysterectomy. vNOTES provides particular advantages in complex cases, including large uteri, obesity, nulliparity, and pelvic adhesions. Emerging variants such as TNH, iNH, and RvNH show promising feasibility but require further validation. The relatively short learning curve of vNOTES supports its broad clinical adoption. vNOTES hysterectomy is a transformative advancement that complements existing minimally invasive techniques and offers a strategic opportunity to revive the declining vaginal route. The versatility, evolving technical adaptations, and potential for global scalability of vNOTES make it a key modality in gynecologic surgery. Successful dissemination relies on structured training, standardized guidelines, device development, and long-term safety data.

Objective: This study aimed to evaluate the association between grade ≥2 chemotherapy-induced leukopenia (CIL) and 3-year post-recurrence survival (PRS) in patients with recurrent cervical cancer (CC) undergoing systemic chemotherapy.

Methods: We conducted a retrospective comparative cohort study of patients with recurrent CC who received ≥3 cycles of systemic chemotherapy at a tertiary referral center between January 2000 and June 2022. Complete serial blood counts were performed for each cycle. Patients were classified according to the development of grade ≥2 leukopenia (white blood cell count <3,000 cells/μL) within the first 3 cycles. Three-year PRS was analyzed using Kaplan-Meier estimates and Cox proportional hazards models.

Results: Among 164 patients (mean age 52.4±11.0 years), leukopenia G2+ occurred in 29 patients (17.7%). Median 3-year PRS was significantly longer in the leukopenia G2+ group than in the non-leukopenia G2+ group (28.9 vs. 17.5 months). The 3-year PRS rates were 38.8% and 16.9%, respectively (P=0.022). On univariate analysis, longer intervals from complete clinical remission to recurrence, platinum regimens, and grade ≥2 leukopenia were associated with improved survival. Multivariate analysis confirmed that leukopenia conferred a 47% reduction in mortality risk (hazard ratio, 0.53; 95% confidence interval, 0.31-0.91; P= 0.021).

Conclusion: CIL during early treatment cycles was independently associated with superior survival in patients with recurrent CC. In the absence of infectious complications, leukopenia may reflect adequate pharmacodynamic drug exposure and host treatment response. It should be interpreted as a post-hoc prognostic indicator, supporting its potential role as a pragmatic surrogate marker of chemotherapy efficacy.

High-risk human papillomavirus (hrHPV) is an important cause of cervical cancer. hrHPV testing has emerged as an effective screening modality to address the limitations of cytology-based screening. However, in Korea, the absence of standardized clinical guidance has resulted in variability in practice. This consensus-based clinical practice guideline was developed by a multidisciplinary expert committee under the Korean Society of Gynecologic Oncology and includes specialists in gynecologic oncology, pathology, laboratory medicine, and public health. Relevant domestic and international evidence was systematically reviewed and perspectives from diverse clinical settings were incorporated through four public hearings. The final recommendations were established through expert consensus. These guidelines present four key recommendations. First, hrHPV testing may be considered for women aged ??5 years, with a screening interval of 3 to <5 years. Second, screening assays should differentiate between HPV genotypes 16 and 18 while detecting other high-risk types, and tests with established clinical validity are recommended. Third, hrHPV testing should be performed in appropriately equipped settings, following standardized procedures for specimen handling and reporting, with clear documentation of HPV 16/18 status in positive cases. Fourth, the testing should operate under rigorous internal and external quality control systems to ensure reliability and consistency. These guidelines aim to promote consistent and evidence-based implementation of hrHPV testing for cervical cancer screening in Korea, supporting early detection and prevention.

Preterm birth remains the leading cause of neonatal morbidity and mortality worldwide, affecting approximately 13.4 million births annually. Despite advances in our understanding of risk factors, current clinical prediction methods have demonstrated limited accuracy in individual risk stratification. This narrative review examines the current landscape of artificial intelligence (AI) applications for preterm birth prediction and evaluates the methodological quality and clinical applicability across different data modalities. PubMed, Embase, and Web of Science were searched to develop and validate machine learning models for predicting spontaneous preterm births. AI approaches include electronic health record-based models, deep learning for ultrasound image analysis, cervical texture and radiomics feature extraction, elastography-derived parameters, and multi-omics integration using transformer architectures. Area under the receiver operating characteristic curve values range from 0.61 to 0.94 across modalities. However, the systematic reviews identified significant methodological limitations; 79% of the studies had a high risk of bias according to the PROBAST criteria, with a median transparent reporting of multivariable prediction model for individual prognosis or diagnosis (TRIPOD) adherence of only 49%. Common deficiencies include inadequate sample sizes, a lack of external validation, and failure to report calibration metrics. Although AI-based prediction shows promise, substantial improvements in methodological rigor are required before clinical implementation. Priority areas include rigorous external validation, adherence to TRIPOD+AI reporting standards, and prospective evaluation of clinical utility.

Objective: To evaluate the clinical utility and implementation considerations of artificial intelligence (AI)-based fetal health classification systems using the Kaggle Fetal Health Classification dataset, with a focus on obstetric physicians' perspectives.

Methods: We analyzed the Kaggle Fetal Health Classification dataset (n=2,126), containing 21 cardiotocography parameters. Five machine-learning algorithms were evaluated: logistic regression, random forest, gradient boosting, support vector machine, and decision tree. Class weighting was applied to address the dataset imbalance. The model performance was assessed using standard classification metrics. An expert opinion-based clinical utility assessment framework was developed to assess interpretability, workflow integration, and safety.

Results: With class weighting applied, gradient boosting achieved the highest accuracy (89.67%), followed by random forest (88.50%) and logistic regression (82.16%). The most important predictive features were abnormal short-term variability (16.23% importance) and the percentage of time with abnormal long-term variability (13.21% importance). An analysis of all 21 features revealed that contraction-related parameters, including uterine_contractions, contributed minimally to the classification performance. The 35.3% false negative rate for pathological cases represents a significant safety concern and requires physician oversight.

Conclusion: AI-based fetal health classification systems show potential for future applications when properly validated. However, the significant false negative rate for pathological cases indicates that these systems cannot function independently. External validation using multicenter clinical data and prospective outcome studies is essential before clinical implementation.

Objective: To determine whether hysterectomy for benign diseases is associated with the risk of dementia in middle-aged women.

Methods: We conducted a retrospective cohort study using data from the Korean National Health Insurance Service database (2002-2020). Women aged 40-59 years who underwent hysterectomy for benign indications (n=16,818) were propensity score-matched (1:1) to controls who had not received hysterectomy. Subjects were followed up until the diagnosis of dementia, death, or the end of the study period (2020). Dementia (all types), Alzheimer's disease (AD), and vascular dementia (VaD) were identified by International Classification of Diseases, 10th revision codes. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for dementia associated with hysterectomy.

Results: Median follow-up was 11.4 years. Dementia occurred in 302 (1.8%) women who did not undergo hysterectomy and 257 (1.5%) women who underwent hysterectomy (P=0.061). Cox analysis revealed that hysterectomy was not significantly associated with all-cause dementia (HR, 0.865; 95% CI, 0.724-1.033), with a non-significant trend towards reduced risk. Subgroup analysis also failed to identify any significant association; AD (HR, 0.696; 95% CI, 0.463-1.048) and VaD (HR, 0.625; 95% CI, 0.284-1.377) were not elevated. These findings held across age subgroups and sensitivity analyses (e.g., laparoscopic hysterectomy: HR, 0.959; 95% CI, 0.691-1.331).

Conclusion: In this large Korean cohort, hysterectomy for benign diseases in women aged 40-59 years was not associated with a significant change in the subsequent risk of dementia. Collectively, our results indicate that hysterectomy (with or without adnexal surgery) did not increase the incidence of dementia.

The external cephalic version (ECV) is a manual procedure that rotates the fetus from breech to cephalic presentation through external abdominal manipulation. Major international guidelines recommend offering ECV at term to eligible women to reduce cesarean delivery rates. However, detailed technical guidance and standardized perioperative management remain limited. This review aims to provide a practical and clinically applicable guide based on an established institutional protocol, covering key preparatory measures, including patient selection and informed consent, a reproducible step-by-step technique, and post-procedure management. ECV is generally indicated for singleton breech pregnancies at or beyond 37 weeks of gestation, when vaginal birth is not contraindicated. Informed consent is required as an elective procedure, supported by balanced counseling on risks, benefits, and shared decision-making. Preprocedural management includes ultrasound assessment, fetal monitoring, and the use of ritodrine hydrochloride and neuraxial analgesia to enhance comfort and facilitate uterine relaxation. This technique emphasizes complete disengagement of the fetal buttocks, direction-specific wide-arc rotation of the fetal head while maintaining continuous upward lifting of the fetal buttocks, and secure engagement of the head beneath the pubic symphysis to prevent reversion. This step is followed by ultrasound confirmation that no umbilical cord or fetal extremity is present before the head. Safety was reinforced by performing the procedure in an operating room with immediate access for cesarean delivery and appropriate postprocedure monitoring. By offering a concise, reproducible approach and a supplementary procedural video, this review supports safer and more effective implementation of ECV and may help reduce unnecessary cesarean births.

Objective: POLE mutations in endometrial cancer play a key role in defining the molecular profile and have important therapeutic implications. These mutations are associated with a favorable prognosis, likely because of enhanced immune responses and tumor immunogenicity. This study aims to refine risk stratification, guide treatment strategies, and support the role of POLE mutations as prognostic biomarkers, particularly in immunotherapy-based approaches.

Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 framework and is registered on PROSPERO (CRD420251064413). Cohort studies published between 2018 and 2025 were identified through major databases. Study quality was assessed using the quality in prognostic studies tool. Hazard ratios (HRs) for overall survival (OS), disease-specific survival, and progression-free survival (PFS) were analyzed using Review Manager 5.4 and R statistical software (Cochrane Collaboration, London, United Kingdom), with heterogeneity assessed using the I² statistic. Publication bias was evaluated using funnel plot analysis, Egger's test, and the Trim-and-Fill method.

Results: POLE mutations were identified in 9% of endometrial cancer cases (95% confidence interval [CI], 9-11%; I²=90.6%; P<0.0001). Patients with POLE mutations showed significantly improved PFS (HR, 0.37; 95% CI, 0.26-0.53; I²=0%) and OS (HR, 0.57; 95% CI, 0.40-0.79; I²=41%). Most cases were early stage (International Federation of Gynecology and Obstetrics I-II, 86%), endometrioid type (84%), with low myometrial invasion (<50%; 56%), limited lymphovascular space invasion (25%), and low lymph node metastasis (29%).

Conclusion: POLE mutations in endometrial cancer are associated with a favorable prognosis and show promising potential for immunotherapy. Molecular subtyping that incorporates POLE mutation status should be considered standard practice for risk stratification and treatment planning.

Objective: The objective of this report is to demonstrate the feasibility of combining the harvested semitendinosus tendon technique (HoTT) technique, originally described laparoscopically, with a retroperitoneal vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach for central compartment prolapse repair.

Methods: A 55-year-old woman with stage III uterine prolapse underwent native tissue sacropexy using an autologous semitendinosus tendon via the retroperitoneal vNOTES approach. Via a pararectal entry, the longitudinal ligament was identified, and the uterus was fixed to the longitudinal ligament of the sacrum using the semitendinosus tendon. The procedure combined native tissue repair with minimally invasive access through the vaginal route.

Results: The result was an anatomically successful prolapse correction without any intraoperative or postoperative complications. The patient recovered well and was discharged after 48 hours.

Conclusion: In conclusion, this is the first case to combine vNOTES with the HoTT technique, enabling a minimally invasive, mesh-free, and anatomically precise prolapse repair. vNOTES offers precise dissection and sacral fixation using a vaginal approach. This should lead to fast recovery and reduced postoperative pain. A retroperitoneal approach allows faster operation times and prevents intraperitoneal adhesions. This technique is promising for patients desiring a mesh-free approach. This innovative approach may serve as a promising alternative to conventional techniques in selected patients.