Journal of minimally invasive gynecology最新文献

Objective: Recent advancements of minimally invasive gynecologic surgery have led to the development of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) [1,2]. Robot-assisted vNOTES has also been explored as a method providing accurate and fine surgical procedures with improved ergonomics, visualization, wristed instruments, elimination of the hand tremor [3,4]. The objective of this video is to demonstrate the technical and anatomical highlights of a vaginal assisted NOTES hysterectomy (VANH) using the da Vinci SP (SP).

Setting: An urban general hospital. Stepwise demonstration of the technique with narrated video footage.

Participants: A 51-year-old woman, para 2 with no previous history of abdominal surgery, who presented with dysmenorrhea and urinary frequency. Magnetic resonance imaging revealed a large uterus with multiple fibroids.

Study objective: To investigate whether intracervical injection of terlipressin during hysteroscopic surgery could reduce the amount of intravasation, the incidence and severity of gas embolism, and the COHb levels in the blood.

Design: Randomized double-blind controlled trial.

Setting: Gynecologic surgical unit in a general hospital.

Patients: Patients who were scheduled for transcervical resection of type 1 or type 2 myomas (TCR-M), or for extensive transcervical endometrium resection (TCR-E).

Interventions: Patients were randomized to receive either terlipressin 0.85 mg or placebo injections intracervically at the beginning of the procedure.

Measurements: The amount of intravasation and level of COHb was measured at the end of the procedure. The incidence and severity of gas embolisms was determined during the procedure by transesophageal echocardiography (TEE). Study groups were compared using an Independent Samples T-Test or a Mann-Whitney U test as indicated.

Main results: Forty-four patients were included in this study. No significant differences were found in intravasation volume, venous emboli and post-surgery COHb between study groups. There was a trend towards more severe embolisms (grade IV embolisms: 12 versus 6, p = .08), paradoxical embolisms (4 versus 2, p = .55) and a shorter operation time (mean of 43 versus 36 minutes, p = .09) in patients who received terlipressin compared to placebo.

Conclusion: This study could not demonstrate a clear beneficial effect of intracervical terlipressin administration. However, further research is needed to investigate if terlipressin can reduce operation time, severe embolisms and the need for redo procedures.

Objective: To determine the efficacy of intravenous (IV) tranexamic acid (TXA) in reducing blood loss and blood transfusion among women undergoing total colpocleisis.

Design: Double-blind, randomized, placebo-controlled trial.

Setting: Tertiary academic urogynecology practice.

Participants: Consenting women undergoing total colpocleisis (±midurethral sling) for treatment of posthysterectomy pelvic organ prolapse.

Interventions: Participants were randomly assigned to a single dose of 1 gram TXA or placebo after anesthesia induction. Primary outcome measures were the differences in preoperative hemoglobin (hgb) and hematocrit (hct) compared to those measured 24 hours after surgery. Secondary outcomes included the difference in intraoperative blood loss and the need for blood transfusion during hospital stay. Safety outcomes were assessed six weeks postoperatively.

Results: Thirty participants completed the study (TXA: 14; placebo: 16). Preoperative variables were similar between groups. Intraoperative outcomes were also comparable, and all surgeries were completed under general anesthesia. No significant differences were observed in any blood loss outcomes between groups (TXA versus placebo differences: hgb 3.2g/dL versus 2.6g/dL, P=.41; hct 0.09 versus 0.08, P=.25; intraoperative blood loss 340mL versus 405mL, P=.58). One patient in the TXA group received a blood transfusion one day after surgery due to medically significant anemia. There were no significant adverse events related to the study intervention in the TXA group.

Conclusion: This study showed no statistically significant differences in blood loss outcomes with the use of IV TXA at the time of total colpocleisis (±midurethral sling). While TXA administration showed no advantage regarding blood loss, it demonstrated no significant adverse effects. This study reinforces judicious use of TXA at the time of colpocleisis rather than using it prophylactically.

Study objective: To explore the associations between adenomyosis patterns on transvaginal sonography (TVS) and surgical outcomes.

Design: A retrospective cohort study.

Setting: Peking Union Medical College Hospital, Beijing, China.

Patients: The medical records of 322 patients diagnosed with adenomyosis who underwent open or laparoscopic fertility-sparing surgeries from March 1 to December 31, 2018, were reviewed. Patients were divided into localized (221 patients) and diffuse (101 patients) adenomyosis groups on the basis of TVS findings.

Interventions: Detailed epidemiological information, imaging evaluations, surgical reports, and pathological findings were retrospectively collected.

Measurements and main results: The median postsurgical follow-up period was 52.8 months (range 6-88 months), with 24 patients (7.4%) lost to follow-up by July 1, 2019. The localized and diffuse adenomyosis groups had similar symptom relief and recurrent uterine lesions. Among the 104 patients who attempted pregnancy, 75 patients (72.1%) conceived, with 35 miscarriages (46.7%) and 59 live births (78.7%). For the whole cohort and the localized adenomyosis and diffuse adenomyosis groups, the cumulative 5-year conception rates were 75%, 83% and 60%, respectively; the cumulative 5-year live birth rates were 63%, 79% and 37%, respectively. The adenomyosis patterns found during sonography were the only independent risk factors related to clinical pregnancy and live birth in the Cox regression model. Patients with diffuse adenomyosis had significantly lower rates of conception (HR 0.5, 95% CI 0.3-1.0) and live birth (HR 0.4, 95% CI 0.2-0.8).

Conclusion: Adenomyosis patterns (localized versus diffuse) in pretreatment TVS could predict obstetrical outcomes, irrespective of surgical type and uterine size.

Clinical registry: The clinical trial registry name is the Cooperative Adenomyosis Network (CAN); the registration number is NCT03230994 (https://clinicaltrials.gov). This study started on June 30, 2017, and was completed on December 30, 2020.

Objective: On September 1, 2021, abortion became illegal in Texas once embryonic cardiac activity is detected. The aim of this study was to compare women's characteristics undergoing surgical sterilization before and following the change in abortion-banning laws in Texas.

Design: A retrospective study.

Setting: Single tertiary medical center.

Patients or participants: All women that underwent bilateral salpingectomy for surgical sterilization between May 2020 to November 2022.Women who underwent surgery 15 months before the new laws (controls) were compared to women who underwent surgery 15 months after the change (study group).

Interventions: Demographic and clinical characteristics were collected from the women's medical files. Operative and postoperative data was collected from the operative reports and post-operative follow-up visits. Primary outcome was defined as the proportion of the women undergoing sterilization in each study period (15 months) calculated as percent of the total number of women included in the study (30 months).

Measurements and main results: 205 women met inclusion criteria, of them 131(64%) were in the study group and 74(36%) controls (p<0.001). The Median age was found similar between the groups [31(27-35) and 31(27-34) years for the study group and controls, respectively;(p=.98)]. The number of women with private insurance was significantly higher in the study group (p=0.04). Parity was significantly higher in the control group, as evidenced by the proportion of nulliparous women, which was more than double in the study population compared to controls [37 (28%) vs. 8 (11%); p = 0.004]. Surgery as the first contraception method was reported in 63(48%) and 41(19%) of the women in the study and control groups, respectively (p=.58). The surgical approaches did not differ between the groups (p=.63). The complication rate was found higher for the study group, but the difference did not reach significance (p=.13).

Conclusions: Surgical sterilization has significantly increased since the change in abortion banning laws in Texas. Although the mean age to undergo the surgery did not change, more nulliparous women preferred this method for contraception.

Study objective: To compare the aggregate fibroid specimen weights between abdominal and minimally invasive (MI) myomectomies to determine whether fibroid burden significantly impacts surgical approach to myomectomy.

Design: Retrospective cohort study; INTERVENTIONS: Comparison of aggregate fibroid specimen weights between abdominal and MI myomectomies SETTING: Community health care system.

Patients: 281 patients undergoing abdominal and MI myomectomies between March 2018 and December 2023.

Measurements/main results: A total of 281 patients underwent a myomectomy in our health system between 2018 and 2023. One-hundred and twenty-four (44.2%) patients had aggregate fibroid weights less than 250 grams, sixty-seven (23.8%) patients had a fibroid weight between 250 and 500 grams, and ninety (32.0%) patients had fibroid weights greater than 500 grams. Abdominal myomectomies had a higher percentage of fibroids with aggregate weight greater than 500 grams (48.5% vs 16.6%), and were associated with higher fibroid specimen weights overall (median 482 grams vs 204 grams for MI). However, after adjusting for age, BMI, race, and insurance and comparing median weights between the approaches by the following categories: less 250 grams, 250-500 grams, and greater than 500 grams, abdominal myomectomies were associated with higher fibroid weight for only the less than 250 gram weight group.

Conclusion: Abdominal myomectomies overall were associated with a higher fibroid weight compared to MI myomectomies. However, when looking at myomectomies with aggregate fibroid specimen weights of 250 grams or greater, abdominal myomectomies were not associated with greater specimen weight than with MI approaches. This study supports the growing utilization of minimally invasive approaches for myomectomies in patients with large fibroid burden.

Study objective: The association between endometriosis and congenital uterine anomalies (CUAs) has been discussed for decades, but existing evidence about this association is scarce. The aim of our study is to evaluate the prevalence of CUAs in women with endometriosis and to identify specific characteristics in women with both CUAs and endometriosis in a large cohort of patients.

Design: This is a retrospective single-center observational study conducted between January 2006 and June 2021.

Setting: Swiss tertiary hospital PATIENTS: Women with histologically confirmed endometriosis at laparoscopy.

Interventions: All women included in this study underwent a preoperative 2D ultrasound by an experienced sonographer. In cases of suspected intrauterine pathology, bleeding disorders, or infertility, an additional hysteroscopy was performed.

Measurements and main results: Out of 1566 women with histologically confirmed endometriosis, 93 were diagnosed with CUAs (5.9%). The most frequent malformations were U1c (arcuate uterus) (41/93, 44.1%), U2a (partial septate uterus) (19/93, 20.4%), U3b (complete bicorporeal uterus) (17/93, 18.3%) and U3a (partial bicorporeal uterus) (10/93, 10.8%). Women with both CUAs and endometriosis were more frequently diagnosed with endometriosis rASRM stage IV (p=0.017) and presence of dysmenorrhea (p=0.019) in comparison to women with endometriosis and a morphologically normal uterus.

Conclusions: To the best of our knowledge, this is the largest endometriosis population examined for the prevalence of CUAs. According to our findings, the prevalence of CUAs in women with endometriosis does not appear to be higher than in the general population. However, women with CUAs and endometriosis are more likely to suffer from severe endometriosis (rASRM stage IV) and dysmenorrhea compared to endometriosis patients without CUA.