Gynaecological Endoscopy最新文献

We present an unusual case of torsion of a paratubal cyst in the mesosalpinx, associated with a defect of the omentum, in which laparoscopic management proved effective. A large paratubal cyst in the left mesometrium which was twisted twice around the defect of the omentum was removed laparoscopically. The patient's postoperative course was uneventful. Early diagnosis and treatment by laparoscopy are essential in the management of adnexal torsion.

As an increasing number of women without pathological findings suffer from chronic pelvic pain (CPP) it has become necessary to use simple treatments involving relatively few complications. From January 1994 to March 1997, 108 patients with CPP underwent diagnostic laparoscopy at our unit. The most frequent findings were endometriosis (33.3%), pelvic adhesions (23.1%), Allen–Masters syndrome (3.7%) and pelvic congestion (2.8%). In 14.8% of the patients with CPP, diagnostic laparoscopy did not reveal any pathological findings in the pelvis. This latter group of patients were treated by means of dissection of the uterosacral ligaments performed at the same time as the diagnostic laparoscopy. None of them had experienced a sustained response to treatment with analgesics and psychological intervention. At 3 months after the operation 50% of the patients who presented for follow up were completely free of symptoms, with an additional 35.7% showing a significant alleviation of pain. There was little change in these percentages 12 months after treatment. No surgical complications were observed. We conclude that this procedure represents a promising alternative treatment for patients with chronic pelvic pain.

Large bowel perforation associated with laparoscopic surgery is a serious complication but even if suspected, it may prove difficult to find and therefore treat. Five interesting cases are reported.

To compare the quality of the vaginal attachment of classical Burch anterior colposuspension with laparoscopic colposuspension with polyester mesh fixed with tackers.

The study was performed on three fresh cadavers. The extension and the strength of polyester braided fibre (Ticron) sutures on one side were compared with those of polyester mesh (Mersilene) tacked into the Burch site on the other side, by means of progressive traction measured by a linear transducer.

When progressive traction was applied in the two systems studied, both displayed moderate elongation. The Mersilene mesh appeared to be significantly more elongated than Ticron suture, with a partial return to the original length. In no case (Ticron suture or tacked Mersilene mesh) was a rupture of the vaginal fixation seen, when traction of up to 2 kg was applied.

Mersilene mesh appears to elongate more than the classical suture when placed under traction. This casts doubt on the quality of the suspension obtained, even though no rupture was observed.

Objective

To assess and compare the efficacy of NovaSure, a novel 3-D bipolar endometrial ablation system, for women with severe menorrhagia secondary to dysfunctional uterine bleeding (DUB), with and without endometrial preparation.

Study design

A prospective, double-arm, controlled, observational pilot study of 40 women undergoing endometrial ablation using the NovaSure system.

Patients

40 premenopausal women, of average age 44 years, with menorrhagia secondary to DUB and unresponsive to medical therapy, who had completed childbearing, with non-distorted uterine cavities, and cornu-to-cornu measurement of greater than 2.5 cm.

Interventions

Endometrial ablation using the 3-D bipolar NovaSure system.

Methods

50% of the patients received gonadotrophin-releasing hormone (GnRH) agonist for endometrial thinning. The remaining patients received no treatment for endometrial thinning. Pictorial blood assessment chart (PBLAC) diary sampling was used to select patients for the study, as well as to conduct the post-treatment evaluation of menstrual blood loss and bleeding pattern (amenorrhoea, spotting, hypomenorrhea, eumenorrhoea or menorrhagia). All patients received the treatment under intravenous sedation with paracervical block.

Results

No intraoperative complications were observed. Treatment time averaged 72 seconds. Follow up of 12 months has been completed in 29 patients. No significant difference was observed in the outcome (i.e. efficacy) of the procedure between the two groups of patients.

Conclusions

Preliminary results indicate that the NovaSure system can be successfully used as an effective method of treatment for women with menorrhagia secondary to DUB. Endometrial pretreatment appears not to be necessary in global ablation performed using the NovaSure system.

Objective

To determine whether goserelin (Zoladex^TM; AstraZeneca, London, UK), plus surgery offers advantages over surgery alone in the management of ovarian endometriomas.

Design

Prospective, multicentre, randomized, open-label, parallel-group study.

Interventions

Following preoperative aspiration of endometriomas, they were sized by ultrasound, a diagnosis of endometriosis confirmed by laparoscopy and its severity assessed. Patients were stratified according to endometrioma size and randomly allocated to one of two groups: group 1 (G1; n = 21) received a monthly (every 28 days) subcutaneous injection of goserelin 3.6 mg for 3 months (12 weeks); group 2 (G2; n = 27) received no treatment. At 3 months, the size of endometriomas was reassessed in both groups before definitive excision. Both groups were reassessed at 6 months postsurgery.

Main outcome measures

Change in size of the largest endometrioma from entry to just prior to excision.

Results

The mean change in endometrioma size was −2.29 cm in G1 and −1.29 cm in G2. The resulting (adjusted) mean difference of −1.25 cm was statistically significant in favour of G1 (P = 0.036, 95% CI −2.42 to −0.08 cm). Very difficult surgery was reported in four (22%) patients in G1 and 10 (46%) patients in G2. Mean duration of surgery was 74.2 min in G1 and 86.4 min in G2. There was a trend towards a greater reduction in mean Additive Diameter of Implants (ADI) score at 6 months postsurgery in G1 compared with G2 (−65.9 vs. −56.6). Both groups were comparable in terms of the number of complete excisions of their endometrial cysts at surgery, blood loss at surgery, Revised American Fertility Society (R-AFS) scores and pelvic symptoms. Goserelin was well tolerated.

Conclusions

Laparoscopic aspiration of endometriomas followed by a monthly goserelin 3.6 mg depot for 3 months compared with laparoscopic aspiration alone results in significantly smaller endometriomas at 3 months and a trend towards a greater reduction in ADI score.

To determine the value of laparoscopic uterine nerve ablation (LUNA) as part of the laparoscopic laser treatment of painful endometriosis.

A prospective randomized double-blind controlled trial.

A referral centre for the treatment of endometriosis.

51 women with pelvic pain and pelvic endometriosis.

All patients underwent laparoscopic laser ablation of their endometriosis and were then randomly allocated to receive LUNA or no further treatment.

Dysmenorrhoea, dyspareunia and chronic non-menstrual pelvic pain were assessed using visual analogue scales and structured questionnaires, preoperatively and at 3 and 6 months postoperatively.

24 patients were randomly allocated to receive laser vaporization alone, and 27 to receive a LUNA procedure in addition. The mean age of the patients involved was 28 years (range 20–41), with no differences between the groups for stage of endometriosis. Comparisons were made between the two treatment groups at 3 and 6 months. Significant differences in favour of the non-LUNA group were found at 3 months (P = 0.003), and at 6 months (P = 0.022) for dysmenorrhoea. A significant difference in favour of the non-LUNA group also occurred at 6 months for chronic non-menstrual pain (P = 0.323). There were no significant differences recorded for dyspareunia. Bonferroni's adjustment was applied, and the only difference which remained significant was for dysmenorrhoea at 3 months (P = 0.033) in favour of the non-LUNA group. The preoperative and 6-month pain scores for all the patients were combined. There was a significant improvement in the pain scores recorded at 6 months (P < 0.0001).

Laparoscopic laser ablation of endometriosis is confirmed as an effective treatment, to which uterine nerve ablation adds no benefit.

To determine current research activity and establish views on the direction of future research in gynaecological endoscopy.

A self-administered structured questionnaire was posted to 389 UK gynaecologists to enquire about current research activity and collect their views on future research within gynaecological endoscopy.

Members of the British Society of Gynaecological Endoscopy (BSGE).

The postal questionnaire was returned by 100 BSGE members (26% response rate) and of these respondents, 47 (47%) were actively involved in research. The majority of respondents (99/100, 99%), believed that the BSGE should play a proactive role in directing future research in gynaecological endoscopy. Therapeutic laparoscopy was the area of gynaecological endoscopy identified most frequently (80/100, 80%) for future study. Within this area, 22/80 (28%) specified the need for studies into laparoscopic treatment of endometriosis, especially comparative studies between ablative and excisional treatment (15/22, 68%).

There is a substantial commitment to research in gynaecological endoscopy by BSGE members who responded to the survey. The BSGE should play a proactive role in defining its research remit in health technology assessment. Future research requiring priority should focus on determining the effectiveness of laparoscopic methods of treatment for endometriosis.

To determine the relative benefits of minimal access surgery (MAS) as perceived by patients and health care professionals.

Prospective descriptive study (design classification III).

A large undergraduate teaching hospital in the North Thames Region.

100 patients (50 gynaecological, 50 antenatal), 70 obstetricians and gynaecologists, and 30 senior hospital managers.

A specially designed questionnaire was used which included 44 pairs of clinical scenarios for laparotomy and laparoscopy. Each scenario consisted of different permutations of four of the variables, incision size, operating time, major complication rate, hospital stay and recovery time. Respondents were asked to select their preferred route of surgery. They also ranked, in order of priority, the above five variables together with treatment cost.

MAS was preferred by the majority. Most patients chose endoscopy even if the operating time was four times longer and there was no reduction in hospitalization, and 25% accepted a quadrupling of the major complication rate. A minority of surgeons chose laparoscopy if the operating time exceeded 2 h or the risk of a major complication was increased fourfold. Most respondents preferred MAS, even if recovery time was equal to that of laparotomy. All respondents ranked complication rate as the main priority and cost as the least. Overall, patients were significantly more in favour of MAS than were surgeons, and the views of managers were in between the views of these two groups.

Both health care professionals and patients, especially the latter, prefer MAS to conventional surgery, even if the operating time is longer and the major complication rate is higher.