Journal of minimally invasive gynecology最新文献

Objective: To compare the long-term efficacy of conventional laparoscopic sacrocolpopexy with those of robot-assisted laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse.

Design: Retrospective cohort study.

Setting: Tertiary referral center in China.

Patients: A total of 139 patients -74 having laparoscopic and 65 robotic-assisted sacrocolpopexy between January 2015 and December 2021 were included.

Interventions: Either laparoscopic or robotic-assisted sacrocolpopexy.

Measurements and main results: The median follow-up times of the laparoscopic group and robotic-assisted group were 60 (interquartile range 39-91) and 46 (interquartile range 38-73) months, respectively. Compared with laparoscopy, the robotic-assisted group had a shorter operative time (164 ± 37 minutes vs 186 ± 36 minutes; p = .001) with no clinically meaningful blood loss between the groups (76 ± 32.1 mL vs 87.6 ± 33 mL). Mesh exposure occurred in 3 patients (4.1%) in the laparoscopic and 2 patients (3.1%) in the robotic-assisted group. The composite success rate did not significantly differ between laparoscopic and robotic-assisted groups (89.2% vs 90.8%, p = .757). Kaplan-Meier survival analysis also revealed no significant differences in the overall rates of recurrent pelvic organ prolapse between the two groups (p = .915).

Conclusion: There is no difference in the rates of prolapse recurrence or mesh exposure at nearly 4 years between laparoscopic or robotic-assisted sacrocolpopexy. There was an average 20-minute time saving for robotic-assisted procedures, with no clinically important difference in blood loss between the surgical approaches.

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 and main results: 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. After vaginal surgery, the residual myometrium significantly increased from 2.4 mm ± 0.9 mm to 6.6 mm ± 2.4 mm (p <.01) in the moderate group and from 0 mm to 4.4 mm ± 2.2 mm (p <.01) in the severe group. The prevalence of abnormal uterine bleeding was significantly reduced after surgery in both groups (p <.01). Pelvic pain was significantly reduced only in the moderate group (p <.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 vs 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 cesarean section at 38 weeks of gestation in both groups, and no uterine rupture was reported.

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

Study objective: The primary objective of this study was to describe vaginal hysterectomy practice patterns as well as facilitators and inhibitors to performing vaginal hysterectomy among gynecologic surgeons. Secondary objectives were to describe facilitators and inhibitors to the teaching and training of vaginal hysterectomy.

Design: Quantitative analysis of an online survey and qualitative analyses of the one-on-one interviews on gynecologic surgeons was conducted. This study was approved by the IRB.

Setting: Online survey and one-on -one virtual interviews.

Participants: Members of the AAGL and the Society of Gynecologic Surgeons INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 505 gynecologic surgeons completed the survey. Most surgeons were white (66.9%) and had a clinic in North America (67.5%). About 48% of respondents reported "no barrier" to performing vaginal hysterectomies including pathology, visualization and exposure, and performance of concomitant procedures. Higher surgical volume was the only factor most commonly rated by surgeons as enabling teaching of vaginal hysterectomy "quite a bit" (31.3%). Most surgeons agreed that vaginal hysterectomies are important to women's health (82.8%) and that all gynecologic surgeons should be able to perform vaginal hysterectomies (66.3%). In terms of medical education and training, most surgeons thought that residents should be required to achieve competency for vaginal hysterectomy prior to graduation (71.7%) and disagreed (56.0%) that we should eliminate residency graduation requirements for vaginal hysterectomy numbers. From the one-on-one interviews, major themes identified included: Advocacy, Centralizing Efforts, Compensation and Incentives, Cycle of Low Experience, Decreasing Regional Trends, Lack of Industry Support, Transvaginal versus Laparoscopy Culture, Varied Training Targets and Resources, Innovations in Training, and Self-Motivation.

Conclusions: Vaginal hysterectomy remains important to our field. Identified barriers and major themes from this study can direct future efforts to increase its adoption.

Study objective: This study aims to evaluate a liberal postoperative voiding policy after minimally invasive hysterectomies to assess the impact of length of stay in the postoperative care unit (PACU).

Design: This is a retrospective interrupted time series study. Patients were identified 3 months before and after the policy change, and a chart review was conducted of medical records. The study was powered to detect a difference of 60 minutes between the pre- and post-policy groups. Secondary outcomes included post operative urinary retention (POUR), postoperative readmission and urinary tract infections (UTI). Wilcoxon rank-sum tests and Fisher's exact tests were utilized to compare outcomes between the pre- and post-policy groups.

Setting: All surgeries were completed within the division of Minimally Invasive Gynecologic Surgery at a single academic institution.

Participants: Female patients aged 18 and older were included if they had undergone a minimally-invasive hysterectomy for benign indications between August 17, 2022 and February 17, 2023. Exclusion criteria included surgery for gynecologic cancer, concurrent incontinence or pelvic floor surgeries, or if patients had a history of urinary retention or bladder surgery.

Intervention: A new liberal voiding protocol that did not require patients to void prior to discharge.

Measurements and main results: 65 patients were identified for the pre-policy group, and 54 in the post-policy group. There was insufficient evidence to detect a difference in PACU length of stay (median 302 minutes pre vs 250 minutes post) or incidence of POUR or UTIs.

Conclusion: The study concluded that a liberal voiding protocol is a feasible policy change. Although there was no statistically significant difference in the PACU length of stay, there was a trend toward decreased length of stay as the median was lower for this group. The results point toward a liberal voiding policy being safe, without changes seen in rates of POUR or UTIs.

Objective: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is utilised for gynecological procedures globally, however evidence to support its application aside from hysterectomy is lacking. A systematic review to determine feasibility and safety profile of vNOTES for benign gynaecology was conducted.

Data sources: A literature search of MEDLINE, EMBASE, CINAHL, SCOPUS, and CENTRAL was conducted, including all types of studies reporting vNOTES for gynecological indications. After excluding cases with concurrent hysterectomy, the review focuses on procedures for benign indications and oncological procedures are reported separately. Patient characteristics and perioperative outcomes were reported, with pooled analysis for sufficiently powered categories.

Methods of study selection: Fifty-four articles were analyzed, including 7 comparative studies (n = 439) and 1 RCT (n = 34), reporting 2469 cases of vNOTES, including adnexal (tubal and/or ovarian) (43 articles, n = 2261), myomectomy (10 articles, n = 136) and prolapse repair (6 articles, n = 72) in predominantly premenopausal women with BMI <30 kg/m² on pooled analysis.

Tabulation, integration and results: The overall conversion rate was low (1.38%, n = 34) with procedure specific conversion rates of 0.45 to 6.8% for adnexal procedures, 1.47% for myomectomy and none reported for prolapse repair. Overall complication rates were low (3.44%, n = 85) with no associated mortality. Five (0.20%) adhesion-related rectal injuries at colpotomy were noted, all repaired intraoperatively without long-term sequelae.

Conclusion: vNOTES appears feasible based on limited evidence, for uterine-sparing gynecological indications, despite a notable rate of rectal injury at colpotomy. There is a negligible risk of rectal injury observed at conventional laparoscopy and robotically assisted surgery, but similar rate of entry-related gastrointestinal injury. This may be due to the learning-curve or suboptimal case selection, necessitating careful training, assessment, and appropriate patient selection. Surgeons should continue registering prospective vNOTES cases via iNOTESs, to evaluate emerging perioperative trends with global uptake of this novel technique.

Objective: Comparison of the clinical efficacy of hysteroscopic subendometrial injection of platelet-rich plasma (PRP) and intrauterine instillation of PRP for the treatment of intrauterine adhesions.

Design: A Retrospective Cohort Study.

Setting: University hospital.

Patients: Patients who underwent hysteroscopic transcervical excision of adhesions from September 1, 2020, to July 31, 2023, and were treated with PRP in the postoperative period were included.

Interventions: Subendometrial PRP injection group (referred to as SE-PRP group) and intrauterine PRP infusion group (referred to as IU-PRP group) MEASURES AND MAIN RESULTS: A total of 299 patients with moderate-to-severe IUA treated with PRP after Transcervical resection of adhesions (TCRA) were included. The primary outcome metric was the clinical pregnancy rate, and the secondary outcome metrics were the rate of menstrual improvement and the AFS score. The results showed that: the AFS reduction scores was greater in the SE-PRP group than in the IU-PRP group (8 vs 7, p = 0.019); the menstrual improvement rate in the SE-PRP group was higher than that in the IU-PRP group (77.0% vs 52.9%, p < 0.001); and the clinical pregnancy rate in the SE-PRP group was similar than that in the clinical pregnancy rate in the IU-PRP group (28.4% vs 20.4%, p = 0.208). The results of multifactorial logistic regression analysis showed that the clinical pregnancy rate in the SE-PRP group was significantly higher than that in the IU-PRP group (OR = 2.020, 95% CI = 1.050-3.889, p = 0.035). The results of the propensity score matching (PSM) analysis showed that: the median postoperative AFS score reduction was significantly higher in the SE-PRP group than in the IU-PRP group (p = 0.015); and the rate of improvement in menstruation was significantly higher in the matched SE-PRP group (75.0% vs 58.1%, p = 0.027) and clinical pregnancy rates were higher in the SE-PRP group (29.4% vs 16.2%, p = 0.043).

Conclusions: Hysteroscopic intrauterine PRP injection is more clinically effective than intrauterine PRP infusion for patients with moderate to severe intrauterine adhesions, resulting in greater reduction in adhesion scores, improvement in menstrual rate, and increased clinical pregnancy rate.

Study objective: To compare surgical outcomes among patients undergoing minimally invasive myomectomy (MIM) or abdominal myomectomy (AM) with MIGS subspecialists versus general obstetrician/gynecologists (OB/GYNs), and to characterize the complexity of myomectomies by surgeon type.

Design: Retrospective cohort study.

Setting: Quaternary care institution.

Participants: Patients who underwent MIM (laparoscopic or robotic) or AM with a fellowship-trained MIGS subspecialist or general OB/GYN from March 15, 2015 to March 14, 2020.

Interventions: Myomectomy.

Results: Of 609 myomectomies, 460 (75.5%) were MIM, 404 (87.8%) of which were performed by MIGS subspecialists. The remaining 149 (24.5%) cases were AM, 36 (24.1%) of which were performed by MIGS subspecialists. Compared to general OB/GYNs, MIGS subspecialists excised a greater number of fibroids for both MIM (median 3.0 [range 1.0-30.0] vs 2.0 [1.0-9.0], p <.001) and AM (21.0 [10.0-60.0] vs 6.0 [1.0-42.0], p <.001), and had a greater proportion of uteri >20 weeks size for AM (22.2% vs 3.5%, p = .003). Composite perioperative complication rates were significantly higher for general OB/GYNs than for MIGS subspecialists (29.0% vs 11.8%, adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 1.48-4.92). In a subgroup analysis of MIM only, general OB/GYNs had higher rates of composite perioperative complications (28.6% vs 9.9%, aOR 4.51, 95% CI 2.27-8.97), excessive blood loss and/or transfusion (10.7% vs 3.0%, unadjusted odds ratio [OR] 3.92, 95% CI 1.41-10.91), surgery time ≥ 90th percentile (25.0% vs 8.9%, aOR 5.05, 95% CI 2.39-10.64), and conversions to laparotomy (10.7% vs 0.2%, unadjusted OR 48.36, 95% CI 5.71-409.93). For AM only, there were no significant differences in perioperative complication rates between groups.

Conclusion: Fellowship-trained MIGS subspecialists had improved surgical outcomes for MIM compared to general OB/GYNs, with fewer conversions to laparotomy, reduced surgery time, and less blood loss, while outcomes for AM were similar by surgeon type. MIGS subspecialists excised a greater number of fibroids regardless of surgical approach, highlighting a level of comfort in complex benign gynecology beyond endoscopic surgery at our institution.