Journal of minimally invasive gynecology最新文献

Study objective: Obstetrics and gynecology (Ob/Gyn) resident experience with robotic gynecologic surgery has been evaluated at time of graduation, but no specific surgical procedures were identified to differentiate the experiences of residents at each level. This study proposes to determine which factors are correlated with more hands-on robotic surgery experience and resident satisfaction.

Design: An Investigational Review Board-approved, 15-question survey was distributed electronically. Ninety-eight responses were received for a rate of 44%. Linear regression and Analysis of Variance statistical analysis were performed.

Setting: Current residents at 8 Ob/gyn residency programs in the US were surveyed.

Patients: N/A.

Interventions: Survey administration.

Measurement and main results: The majority of respondents were satisfied (48%) or had neutral feelings (20%) with regard to their robotic surgery experience. All respondents reported experience with uterine manipulation or bedside assistance by postgraduate year (PGY) 2. Earliest experience performing hysterectomy was most common in PGY2 or PGY3. Seventy-six percent of PGY3 or PGY4 residents report operating on the console for some or all major robotic surgeries, with 69% having participated in greater than 20 robotic surgery cases during residency. Only exposure to Minimally Invasive Gynecologic Surgery faculty is significantly associated with high robotic surgery experience (p = .022). Overall satisfaction with robotic surgery experience increased significantly with higher level of participation (p <.0001), particularly operating at the console during some or most of the surgery; longitudinal experiences with hysterectomy, myomectomy, and salpingectomy/oophorectomy (p <.05); but not with sole bedside assisting or vaginal cuff closure. Factors limiting robotic console experience included case time constraints, lack of first assists, case complexity, and attending comfort.

Conclusions: Ob/Gyn resident satisfaction with training is significantly related to level and duration of robotic surgery participation. Minimally Invasive Gynecologic Surgery faculty contribute to more resident experience, and limiting factors include time constraints, case complexity, and lack of first assists. These results can provide a framework for structuring resident training in robotic surgery.

Study objective: While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic (CL) salpingectomy for the surgical management of ectopic pregnancy.

Design: Case-control study.

Setting: A London University hospital.

Patients: Women with ectopic pregnancy unsuitable for medical management who underwent surgical management.

Intervention: Twenty-five cases of vNOTES vs 25 CL salpingectomy.

Measurements and main results: The mean patient age (29.7 ± 53 vs 31.4 ± 6.7 days), parity (1.2 ± 1.1 vs 1.6 ± 2.1), body mass index (26.7 ± 5.3 vs 27.2 ± 5.4 kg/m³), gestation age (8.44 ± 2.1 vs 7.3 ± 1.7 weeks) and β human chorionic gonadotrophin (βhCG) levels (3725.4 ± 3674.8 vs 4376.5 ± 6493.4 IU/liter) were comparable (p >.05, t test) between patients having vNOTES vs CL salpingectomy. While estimated blood loss was similar (218.2 ± 491.7 vs 173.5 ± 138.7 mL) (p >.001), vNOTES patients had a statistically shorter duration of surgery (35.8 ± 14.4 vs 75.8 ± 19.7 mins) (p <.001, t test) and length of stay (median: 11.5 vs 19.7 hours) (U = 72, p <.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%), and the median visual analog score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0) (U = 75, p <.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8 ± 4.3 vs 17.1 ± 8.2 days) (p <.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia.

Conclusion: Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain, and more rapid recovery, which help mitigate higher costs incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomized studies are needed.

Study objective: We aimed to evaluate the medium-term outcomes of high uterosacral ligament suspension (HUSLS) with vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) in patients either having pelvic organ prolapse or undergoing routine prophylaxis to prevent posthysterectomy vaginal vault prolapse.

Design: Multicenter prospective cohort study.

Setting: Three tertiary care hospitals.

Patients: Patients who received vNOTES-HUSLS between January 1, 2021, and January 1, 2023, were included in the study.

Interventions: vNOTES-HUSLS.

Measurements and main results: The data collected included surgery duration, intraoperative and postoperative complications, postoperative visual analog scores, and Female Sexual Function Index pain subdomain scores. The changes in prolapse levels were measured using modified Pelvic Organ Prolapse Quantifications System scores, including the C, Ba, and Bp scores recorded before surgery and during the postoperative follow-up examination. Patient satisfaction was assessed using the Patient Global Impression of Improvement questionnaire. The final analysis included 55 women. Of these, vNOTES-HUSLS was performed in 43 patients (78.2%) to treat apical prolapse, whereas the remaining 12 patients (21.8%) underwent prophylaxis after hysterectomy to prevent vaginal vault prolapse. The median follow-up period was 23.5 months, with a range of 12 to 37 months. Ba, C, and Bp points significantly improved in patients who underwent surgery for prolapse (p <.001). There was no recurrence in the apical compartment after vNOTES-HUSLS for both performed prophylactic and treatment purposes after hysterectomy. Two patients (3.6%) were diagnosed as having stage 3 anterior compartment prolapse. The overall vNOTES-HUSLS success rate was 96.4% at approximately 2-year follow-up. Bladder injury was detected as an intraoperative complication in 1 patient (1.8%). The overall satisfaction rate was 98.1% at the final follow-up.

Conclusion: vNOTES-HUSLS was effective in the treatment and prophylaxis of apical prolapse, demonstrating high anatomic success rates. The procedure demonstrated a low complication rate, with intraoperative and postoperative complications each observed in 1.8% of patients (n = 1).

Study objective: To evaluate the efficacy of combining high-intensity focused ultrasound (HIFU) ablation with hysteroscopic removal of retained products of conception in the presence of a uterine arteriovenous fistula (UAVF).

Design: Prospective cohort study SETTING: Tertiary hospital.

Patients: Seventeen patients with UAVF and retained products of conception.

Interventions: HIFU ablation combined with hysteroscopic removal of retained products of conception.

Measurements and main results: All patients presented with irregular vaginal bleeding following pregnancy termination and were not responsive to medical treatment. Patients were confirmed to have a UAVF along with concurrent intrauterine residue using three-dimensional color Doppler ultrasonography, uterine angiography, or pelvic-enhanced magnetic resonance imaging; and demonstrated a poor response to medical treatment. Under real-time ultrasound guidance, HIFU was used to ablate the arteriovenous malformation region. Patients underwent hysteroscopic removal of retained products of conception; the removed tissue was subjected to pathological examination. All patients underwent monthly uterine color Doppler ultrasound examinations and menstrual status follow-up within 3 months postoperatively and showed normal menstrual recovery without signs of arteriovenous malformations on ultrasonography. Pathological examination of the tissues removed during hysteroscopic clearance revealed characteristics consistent with pregnancy, with abnormal blood vessels in some tissues. All patients experienced normal menstrual recovery postoperatively, without intrauterine adhesions.

Conclusion: Combining HIFU ablation with postoperative hysteroscopic surgery effectively treats pregnancy-related UAVF with minimal complications and preserves fertility, it offers an additional treatment option for patients wanting future fertility.

The manuscript showcases images of an extensive ovarian dermoid cyst harboring a mandibular structure containing three teeth. To date, only six case reports have described teeth within a mandibular structure in a dermoid cyst. To the best of our knowledge, this represents the first documented instance of a dermoid cyst with a mandibular structure containing teeth managed through transumbilical laparoendoscopic single-site surgery.

Study objective: To study the inter-rater reliability of an electronic complementary uterine diagram (electronic American Fertility Society [eAFS] freely available at https://bit.ly/eAFS-score) in comparison with the conventional American Fertility Society (cAFS) intrauterine adhesion (IUA) scoring system. As a secondary aim, we wanted to assess the intra-rater reliability of these tools.

Design: This was an observational cross-over study with a nested test-retest design.

Setting: Self-identified gynecologists who performed diagnostic hysteroscopy as part of their routine practice were asked to score IUA on 7 preselected videos using both cAFS and eAFS tools in 2 separate rounds. The order of use of tools was determined at random. Gynecologists who agreed to be involved in a third round were asked to use the tool they were allocated to in the first round to assess intra-rater variability.

Patients: No patients were recruited for the purpose of this study.

Measurements and main results: Inter-rater agreement between evaluators when using eAFS and cAFS for IUA scoring. Overall, the inter-rater agreement was fair (0.25; confidence interval [CI], 0.17-0.34) for cAFS and moderate (0.53; CI, 0.48-0.58) for the eAFS tool. The biggest difference between both tools was seen in the "extent of cavity involved" component, which was fair (0.28; CI, 0.21-0.35) vs substantial (0.71; CI, 0.64-0.78) for cAFS vs eAFS, respectively. Moreover, agreement coefficients were comparable among "expert" and "non-expert" evaluators with the use of the eAFS tool. In addition, intra-rater perfect agreement was higher with the use of eAFS than cAFS (38% vs 32.5%).

Conclusion: The current AFS IUA scoring system has fair inter-rater agreement. However, using a complementary electronic uterine diagram increased this agreement from fair to moderate overall and from fair to substantial in the "extent of adhesions" domain of the tool. The use of the electronic diagram also improved inter-rater agreement among non-experts making it comparable with that of experts.