Journal of minimally invasive gynecology最新文献

Study objective: To compare outcomes of vaginal surgery in women with moderate or severe symptomatic cesarean scar defect (with or without residual myometrium).

Design: Retrospective cohort study.

Setting: Gynecology department of a teaching hospital.

Patients: Fifty-three women, between January 2014 and December 2019, underwent vaginal surgery for symptomatic cesarean scar defect: 20 women with moderate defect (with residual myometrium) and 33 with severe defect (without residual myometrium).

Interventions: Vaginal surgical approach to repair cesarean scar defect.

Measurements: The main objective of this study was to evaluate the efficacy of vaginal surgery by comparing the myometrial residual thickness before and after surgery. The secondary objectives were evaluation of vaginal surgery efficacy on symptoms resolution, per and postoperative courses and subsequent fertility. Failure rate was evaluated as the need for a second surgery.

Main results: After vaginal surgery, the residual myometrium significantly increased from 2.4 ± 0.9 mm to 6.6 ± 2.4 mm (p <0.01) in the moderate group and from 0 mm to 4.4 ± 2.2 mm (p <0.01) in the severe group. The prevalence of abnormal uterine bleeding was significantly reduced after surgery in both groups (p<0.01). Pelvic pain was significantly reduced only in the moderate group (p<0.01). The rate of complications (5 vs. 9.1%) and second surgery (15 vs. 24.2%) were not significantly different between moderate and severe groups respectively. The median time to conceive (7 months versus 12 months); pregnancy rates (84.6 vs. 68.2%); and live birth rates (76.9 vs. 50%) were not statistically significant in the moderate and severe groups respectively, with 90% of pregnancies occurring naturally. Women delivered by caesarean section at 38 weeks of gestation in both groups and no uterine rupture was reported.

Conclusion: Despite the absence of residual myometrium, vaginal 65 repair of severe cesarean scar defect was effective in increasing myometrial thickness, in relieving bleeding symptoms, and in allowing to achieve pregnancy.

Objectives: This study compared patients who underwent myomectomy with preoperative uterine artery embolization (UAE) to those who underwent surgery without UAE. The primary objective was to analyze whether preoperative embolization reduces perioperative blood loss and other related complications. The secondary objective was to analyze the long-term outcomes of the two techniques in terms of fertility and obstetrical complications.

Design: Observational cohort retrospective study approved by the Brugmann University Hospital's ethics committee (CE2023/79).

Setting: The department of gynecology database was used to extract all myomectomy cases between January 2011 and December 2021. Hysteroscopic myomectomies were excluded.

Patients: 192 patients were included.

Interventions: The population was divided according to the presence or absence of preoperative UAE. The UAE and myomectomy group comprised 95 cases between 2011 and 2020, while the myomectomy-only group consisted of 97 cases between 2014 and 2021.

Measurements and main results: Blood loss was significantly lower when preoperative UAE was performed (175.9 [308.5] mL versus 623.3 [697.5] mL, p-value <0.0001). However, there was no significant difference in postoperative haemoglobin, blood transfusion rate or emergent hysterectomy conversions compared to myomectomy as the only treatment. UAE was associated with complications that may result in infertility, such as adhesions (15.3% UAE group vs. 2.2% non-UAE group, p-value 0.02) and an increased incidence of miscarriage in pregnancies (53.5% UAE group vs. 22.3% non-UAE group, p-value=0.01). Furthermore, in cases where a pregnancy did progress following UAE, later obstetrical complications such as abnormal placentation or uterine rupture were common in the series (21.7% UAE group vs. 0% non-UAE group, p-value=0.03).

Conclusion: The findings of our study indicate that, other than a lower estimated blood loss (EBL), preoperative UAE does not appear to improve the outcome of myomectomies, while potentially increasing the risk of fertility and pregnancy related complications.

Objective: The objective of this video is to review a case of a patient that presented to urogynecology clinic for prolapse, but was noted to have anterior vaginal cyst. In this video we review differential diagnosis, embryologic origin of vaginal cyst, excision procedure, imaging and pathology of the vaginal cyst.

Setting: Urogynecology clinic/operating room PARTICIPANT: Patient who presented with anterior vaginal cyst INTERVENTION: 34yo G0 referred to Urogynecology for a vaginal bulge. On exam she had a 4 cm anterior vaginal cystic mass. The differential diagnosis for benign vaginal cysts is broad including Müllerian or Gartner's (mesonephric) ducts, Skene duct, Bartholin gland, epidermal inclusion, or endometriotic cysts, adenosis, or urethral diverticulum (1,2). Most are secondary to embryological remnants or trauma (3). Müllerian ducts form the fallopian tubes, broad ligament, uterus, cervix and upper part of the vagina. Müllerian epithelium is replaced with squamous epithelium of the urogenital sinus; however, Müllerian epithelium can persist anywhere along the vaginal wall. Thus, Müllerian cysts can be found at any location in the vagina (4). During vaginal cyst work-up, imaging can be helpful to further differentiate the cyst and aid in surgical planning. Our patient had an in-office translabial ultrasound that revealed a fluid filled vaginal cyst that had possible bladder connection. Pelvic MRI showed a 4 cm non-communicating fluid-filled cyst that was abutting the bladder in its entirety. We present imaging and a surgical excision video demonstrating the importance of meticulous dissection directly on the bladder wall. The video also presents histopathology slides with bland, endocervical-type columnar epithelium, leading to the final diagnosis of a Müllerian duct cyst.

Conclusion: Vaginal cysts require careful examination and imaging. Understanding their location is crucial for surgical planning, counseling, and successful patient outcomes.

Objective: Fibroids cause significant morbidity, including anemia, pelvic pain, and infertility. It is imperative that healthcare providers are well-versed on the varying treatments available for fibroids. Specifically, uterine artery embolization (UAE) is a treatment that improves anemia, pelvic pain, and quality of life. The purpose of this article is to compare international guidelines on UAE to offer best practices to healthcare providers.

Data sources: Guidelines from the American College of Obstetrics and Gynecology (ACOG), The Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Radiologists, National College of French Gynecologists and Obstetricians (CNGOF), The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the National Institute for Health and Care Excellence (NICE) were reviewed alongside peer-reviewed PubMed articles.

Method of study selection: A comparative review of major international guidelines was conducted to encompass potential geographical, cultural, and societal variances with UAE.

Tabulation, integration, and results: Review of data revealed guidelines agree with many constituents surrounding treatment of fibroids with UAE. Guidelines diverge regarding offering UAE for small fibroids, intracavitary/submucosal fibroids, and pedunculated serosal fibroids with variations on suggested imaging. Most agree that an experienced care team including a gynecologist and interventional radiologist should be included. Preoperative antibiotics and IUD removal may be recommended. UAE for patients who desire fertility remains an option after counseling within most guidelines.

Conclusions: UAE is a safe, efficacious, and cost-effective alternative to hysterectomy and myomectomy. Including UAE as a treatment option during the patient counseling process is critical. Guidelines vary based on data interpretation and are based on clinical research and expert opinion. Due to mixed data and lack of randomized controlled trials, organizations differ when offering UAE to patients who wish to preserve fertility. It is vital to note emerging studies supporting the safety of UAE for subsequent pregnancy.

Study objective: Women with Asherman syndrome are at high risk of recurrent adhesions and pregnancy complications. Spontaneous uterine rupture is a rare but life-threatening complication, associated with severe maternal and fetal morbidity and mortality. Uterine ruptures can occur after extended induction of labor or a history of cesarean section, whereas spontaneous uterine rupture in an unscarred uterus is rare. Aim of this study is to evaluate the incidence of spontaneous uterine rupture among women with Asherman syndrome treated by hysteroscopy and without a history of cesarean section.

Design: Prospective cohort study.

Setting: Asherman Expertise Center of the Spaarne Gasthuis, the Netherlands.

Patients: Women were defined by as patients with Asherman syndrome when they had one or more clinical features and the presence of hysteroscopically confirmed intrauterine adhesions.

Interventions: Hysteroscopic adhesiolysis and a second-look hysteroscopy two months after the initial procedure.

Measurements and results: Data on the severity of adhesions and ongoing pregnancy after treatment were collected prospectively. A total of 428 women with Asherman syndrome were included, 4 women (0.9%) experienced spontaneous uterine rupture. The timing varied, none of the affected women were in active labor and the occurrence of uterine rupture was not related to the severity of adhesions. Ruptures were all found in the fundus. One woman had a history of perforation of the uterine wall located in the fundus. Neonatal outcomes were poor, two cases had intrauterine neonatal death and two cases had long-term lifelong disability. One woman had a second uterine rupture.

Conclusion: Women with Asherman syndrome are at risk of uterine rupture, a pregnancy complication with significant consequences that is challenging to predict and may also be associated with history of uterine perforation. Clinicians should be aware of this risk in women treated with hysteroscopic adhesiolysis and consider counseling these patients accordingly prior to treatment.

Objective: Postoperative pain management significantly influences recovery speed, hospital stay duration, and healthcare costs. In light of inconsistencies in clinical trial outcomes, we conducted a systematic review and meta-analysis to assess the efficacy of the Transversus Abdominis Plane (TAP) block compared to local anesthetic wound infiltration (WI) for postoperative pain management in gynecological surgery.

Data sources: Systematic searches were conducted across PubMed/MEDLINE, ScienceDirect, the Cochrane Library, and Web of Science databases to identify all randomized controlled trials (RCTs) comparing TAP block and WI in adult patients undergoing gynecological surgical procedures. Additionally, the reference lists of the identified studies were manually reviewed. Only studies published in English were eligible for inclusion in the analysis.

Methods of study selection: The Population, Intervention, Comparison, and Outcome (PICO) framework for the review included: (1) adult patients who underwent gynecological surgical procedures; (2) postoperative TAP block as the intervention; (3) comparison with local anesthetic wound infiltration; (4) primary outcome: postoperative pain at 1, 4, 12, and 24 hours; secondary outcomes: postoperative opioid consumption, opioid-related side effects and patient satisfaction. STATA software, version 18 (Stata Corp, College Station, TX, USA), was used for the analysis.

Tabulation, integration, and results: A total of 213 papers were initially identified. Of these, 10 RCTs encompassing a total of 604 patients met the inclusion criteria. The meta-analysis showed that in minimally invasive surgery TAP block was associated with lower pain scores at rest and 1, 4, 12, and 24 hours compared to the WI group. Furthermore, the TAP block resulted in a reduction in opioid consumption at 24 hours, although there was no significant difference in opioid-related adverse effects. Two studies presented data on patient-reported satisfaction, and a pooled analysis was not feasible due to heterogeneity.

Conclusion: TAP block seems to provide better postoperative pain control after laparoscopic gynecologic procedures and reduces opioid use compared to WI in gynecologic surgery.