Journal of minimally invasive gynecology最新文献

Study objective: To evaluate clinical outcomes of hysteroscopic morcellation for evacuation of early pregnancy loss including the rate of post-operative intrauterine adhesions, ability to obtain genetic testing results, and explore risk factors associated with procedural complications.

Design: Retrospective chart study.

Setting: Office or operating room.

Participants: 208 patients for early pregnancy loss who underwent hysteroscopic morcellation and subsequent post-operative saline-infused sonohysterogram.

Interventions: Hysteroscopic morcellation, with or without ultrasound guidance, and a saline-infused sonohysterogram ≥ 1 month post-procedure.

Measurements and main results: Post-operative intrauterine adhesion rate, with secondary measures of complication rate and ability to acquire tissue genetic testing. 177 patients completed their post-operative saline-infused sonohysterogram. There were no post-operative intrauterine adhesion findings in exclusively hysteroscopic morcellation cases. In one case that also included dilation and curettage with hysteroscopic morcellation there was an intrauterine adhesion finding, resulting in an overall intrauterine adhesion rate of 0.6% (1/177). The rate of post-operative retained products of conception was 10.7% (19/177). Genetic testing was successfully obtained for 91.3% of cases (189/207), one patient did not want genetic testing performed. Complications occurred in 8.7% (18/208) of cases, the most common complication being fluid overload, 72.2% (13/18), easily treated with furosemide.

Conclusion: This represents the largest reported cohort to date evaluating hysteroscopic morcellation as the primary treatment for the management of early pregnancy loss. Hysteroscopic morcellation is safe and effective for management of early pregnancy loss with a low rate of complications and intrauterine adhesions post-operatively.

Study objective: To evaluate differences in the likelihood of endometriosis or adenomyosis diagnosis across genetically-defined ancestry groups (African, Admixed American, East Asian, European, and South Asian), and to determine whether social vulnerability and access to surgery influence diagnostic practices in a diverse urban population.

Setting: Penn Medicine BioBank, a clinical and genomic biorepository.

Patients: Female patients aged 18-51 enrolled from 2008 to 2020 and followed through March 2024.

Interventions: Population diversity was characterized using genotyping data from peripheral blood samples. Genetic ancestry was inferred through principal component analysis and clustering with reference populations. Sociocultural factors were assessed as distinct covariates rather than conflated with racial/ethnic identity. Social vulnerability indices (socioeconomic status, family/household factors, and housing/transportation access) were defined by Census tract of the patient's residence. Endometriosis and adenomyosis were identified using International Classification of Diseases-9/10 codes, validated by chart review. Logistic regressions were adjusted for age, body mass index, social vulnerability, and interaction terms.

Measurements and main results: Among 9,258 patients, 357 (3.9%) were diagnosed with endometriosis and 464 (5.0%) with adenomyosis. When all diagnostic routes were considered (surgical, imaging, and clinical), the likelihood of endometriosis did not differ by ancestry group. However, the odds of a surgical diagnosis by laparoscopy was significantly lower for patients of African ancestry, compared with European (adjusted OR 0.57, 95% CI 0.38-0.85). Socioeconomic vulnerability strongly modified this association: African-ancestry patients with the highest socioeconomic vulnerability had the lowest odds of receiving an endometriosis diagnosis (aOR 0.29, 0.14-0.61), including surgically-confirmed diagnosis (aOR 0.31, 0.12-0.80), relative to those of European ancestry with lowest vulnerability. By contrast, patients of African ancestry had higher odds of adenomyosis (aOR 2.88, 2.16-3.85), including cases confirmed by hysterectomy (aOR 3.44, 2.21-5.36).

Conclusion: Diagnostic disparities in endometriosis and adenomyosis were most pronounced at the intersection of ancestry and socioeconomic vulnerability, highlighting the need to address social determinants and barriers to equitable care.

Objective: To evaluate the efficacy of laparoscopic-assisted transversus abdominus plane (LA-TAP) block for minimally invasive gynecological surgeries (MIGS).

Design: Randomized controlled trial.

Setting: Two hospital sites within a tertiary academic healthcare system.

Participants: Eighty participants undergoing MIGS for benign conditions.

Interventions: Participants were randomized to either a control group that received no block (n = 40) or a LA-TAP group (n = 40) which received a standardized mixture of liposomal and plain bupivacaine. No participants received trocar site local infiltration. Primary outcomes were patient-reported average and worst pain at rest and with activity assessed 24 hours after surgery. Secondary outcomes included: (1) average and worst pain with activity assessed at 48 and 72 hours after surgery, (2) opioids used in the post-anesthesia care unit (PACU) and cumulative use after PACU discharge assessed at each 24-hour block (oral morphine milligram equivalents [OME]), (3) time to PACU discharge (4) nausea or vomiting within the first 24 hours (yes/no), and (5) satisfaction with pain regimen. Pain and satisfaction were scored on a scale of 0 to 10 (10 = highest). Outcome assessor and participants were blinded to group assignment.

Results: Final analyses included 34 LA-TAP participants and 30 controls. Worst pain (mean ± SD) at rest within the first 24 hours was lower in the LA-TAP group (4.8 ± 2.7) versus control (6.2 ± 2.3) (p = 0.031). Opioid use in the PACU (mean ± SD) was reduced in the LA-TAP group (13.3 ± 14.1 OME) versus control (22.5 ± 20.1 OME) (p = 0.040). There was no difference in all other pain scores, cumulative opioid use, time to PACU discharge, incidence of nausea or vomiting, or overall satisfaction.

Conclusion: LA-TAP blocks may reduce early postoperative pain and decrease PACU use of opioids after MIGS.

Study objective: To measure the workload effect of an exoscopic camera system during vaginal hysterectomy on workload and learning experience of Obstetrics and Gynecology trainees.

Design: Prospective cohort study SETTING: Two tertiary academic medical centers in the United States PATIENTS/PARTICIPANTS: Obstetrics and Gynecology residents and fellows INTERVENTIONS: Vaginal hysterectomy performed with and without an exoscopic camera system MEASUREMENTS AND MAIN RESULTS: The primary outcome was workload measured using the NASA Task Load Index (NASA-TLX) across six dimensions: mental demand, physical demand, temporal demand, effort, performance, and frustration. The secondary outcomes were trainee perceptions of the surgical experience using Likert scale questions. From June 2021 to January 2024, 39 surveys were completed (21 with camera, 18 without); 10 trainees had paired data. The mean overall NASA-TLX scores did not differ between groups (40.4 [SD 14.9] with camera vs. 47.5 [SD 21.5] without; p=0.14). Physical demand scores were lower with the camera (39.9 [SD 41.3] with vs. 53.1 [SD 19.2] without; p=0.05). Among paired data, median overall NASA-TLX scores were similar (47.4 vs. 49.3; p=0.28), with 7 of 10 trainees reporting lower scores with the camera system. Effect sizes for trainee perceptions showed small positive effects on visualization (Cliff's δ =0.26) and skill building (Cliff's δ =0.29), moderate effect on procedural flow (Cliff's δ =0.46), and large effect on engagement (Cliff's δ =0.50) with the use of the exoscopic camera. No effects were seen for anatomical knowledge application (Cliff's δ =0.04), confidence in anticipation (Cliff's δ =0.06), or intrusion (Cliff's δ =-0.01).

Conclusion: Use of an exoscopic camera system during vaginal hysterectomy was associated with improved trainee engagement and procedural flow, and reduced physical demand, without increasing overall mental workload. These findings support its utility as an educational adjunct in vaginal surgery training.

Summation: In a prospective cohort study, use of an exoscopic camera system during vaginal hysterectomy was associated with improved trainee engagement and reduced physical demand without increasing overall mental workload.

Objective: To demonstrate the laparoscopic, uterus-sparing excision of an accessory cavitated uterine malformation (ACUM) in an adolescent patient and to emphasize the importance of accurate preoperative imaging for intraoperative localization.

Setting: Tertiary referral center for minimally invasive gynecologic surgery.

Participants: An 18-year-old adolescent patient presenting with severe dysmenorrhea and chronic pelvic pain refractory to medical treatment.

Interventions: Laparoscopic excision of a noncommunicating accessory cavitated uterine lesion with preservation of the main uterine cavity.

Conclusion: Preoperative transabdominal ultrasonography and magnetic resonance imaging demonstrated a 35 × 43 mm cystic lesion located in the left anterior uterine wall, clearly separated from the endometrial cavity and consistent with ACUM. During laparoscopy, no obvious uterine bulging was observed, making intraoperative localization challenging. A targeted myometrial incision allowed identification and complete excision of the lesion, which contained chocolate-colored fluid and was lined with endometrium-like tissue. The main uterine cavity was preserved, and layered myometrial reconstruction was performed. Histopathological examination confirmed the diagnosis of ACUM. Laparoscopic uterus-sparing excision is a safe and effective treatment option for adolescent patients with ACUM when guided by accurate preoperative imaging.

Objective: Risk-reducing bilateral salpingooophorectomy (RRSO) lowers the risk of ovarian cancer (OC) by 80-90% in women with a hereditary predisposition to breast and/or ovarian cancer (HBOC/HOC). As genetic testing expands, more women may be candidates for RRSO, which underscores the need to assess the safety of the procedure. We aimed to evaluate the frequency of surgical complications following RRSO to support informed decision-making for women advised to undergo the procedure.

Design: Retrospective cohort study SETTING: Copenhagen University Hospital Herlev, Denmark January 2017-December 2022 PARTICIPANTS: 246 women with HBOC/HOC who underwent risk reducing surgery were included. Patients, who had declined to participate in quality assurance studies were excluded.

Interventions: Risk reducing bilateral/unilateral salpingoophorectomy ± hysterectomy RESULTS: 246 women underwent surgery, and 15 (6.09%) experienced complications. 9 (60%) were Clavien Dindo grade I and 6 (40%) grade II. No grade III, IV, or V complications occurred. Grade I included minor pain or superficial infection not requiring antibiotic treatment, and grade II were all due to infections requiring treatment with antibiotics. No significant differences were found between women with and without complications with respect to age, BMI, previous abdominal surgery or smoking CONCLUSION: The incidence and severity of complications after risk reducing surgery were low. This evidence is valuable in counseling women with HBOC and offers reassurance about the safety of RRSO.