Journal of minimally invasive gynecology最新文献

Study objective: To prospectively assess the prevalence of intrauterine synechia following medically-treated post-partum hemorrhage (PPH) and to evaluate the association between synechiae formation and PPH management techniques.

Design: A prospective observational cohort study SETTING: Angers University Hospital PARTICIPANTS: A total of 83 women presenting with medically-treated PPH from January to December 2021 were included in the study.

Intervention: Diagnostic hysteroscopy was performed twelve weeks postpartum to assess for the presence of uterine synechiae. Detailed data on PPH management techniques were collected for analysis.

Measurements and main results: The majority of participants were primiparous and had undergone vaginal delivery. Only 7% required intrauterine balloon tamponade (IUBT), and 4% underwent uterine artery embolization. Uterine synechiae were identified in 20 women during diagnostic hysteroscopy, yielding a prevalence of 24% at 12 weeks postpartum; all classified as type I according to the ESGE classification system. IUBT was used in 15% of women with synechiae compared to 5% in the non-synechiae group, although this difference was not statistically significant (OR 3.52, 95% CI 0.65-19.10, p=0.123). Multivariate analysis identified second manual uterine examination (OR 5.00, 95% CI 1.50-16.66, p=0.009) and bimanual uterine massage (OR 3.50, 95% CI 1.12-10.09, p=0.020) as independent risk factors for synechiae formation.

Conclusion: This is the first study to evaluate the risk of intrauterine synechiae following medically treated PPH. Mild uterine synechiae were observed in one in four women in the cohort. The need for a second manual uterine examination and bimanual uterine massage were significantly associated with the development of synechiae. Further research is warranted to explore the long-term clinical consequences, including fertility outcomes, and to determine the potential role of diagnostic hysteroscopy in postpartum follow-up after PPH SUMMATION: The study prospectively investigates the prevalence of uterine synechiae following non-surgical postpartum hemorrhage, revealing a 24% occurrence, with second manual uterine examination and bimanual massage identified as independent risk factors.

Study objective: Essure is a hysteroscopic sterilization device that has been used in the Netherlands since 2003. Essure has received a lot of publicity due to many reported symptoms associated with the device. Because of this, increasing numbers of patients requested surgical removal of Essure devices. There is still limited data available regarding the effect of removal surgery on reported symptoms and patient satisfaction. The aim of this study was to analyze the effect of Essure removal surgery on reported symptoms and quality of life.

Design: Multicenter prospective study in the Netherlands.

Setting: Secondary non-teaching hospitals and secondary and tertiary teaching hospitals.

Patients: Patients with Essure associated symptoms and a request for surgical removal of devices.

Interventions: Participants were asked to fill out questionnaires at their first clinic visit and 3 and 12 months after removal surgery. Questionnaires included questions regarding patient characteristics, symptoms and quality of life (SF-36). Clinicians also filled in 2 questionnaires, regarding peroperative findings, the removal surgery and post-operative recovery.

Measurements and main results: 1248 patients in 32 hospitals were included in the period between May 2016 and April 2019. Mean age was 42.9 years (25-63 years). Most frequent reported symptoms were mood swings (72.4%), fatigue (71.8%), pain in hips, legs or groins (68.3%) and abdominal pain (62.3%). Essure was predominantly removed by laparoscopic salpingectomy (87.3%). Mean follow-up time was 17 months (± 10.8). 3 and 12 months after removal surgery all reported symptoms significantly improved. Quality of life improved significantly on all 9 domains.

Conclusion: Essure removal surgery was associated with improvement in reported symptoms and quality of life. Patients presenting with Essure related symptoms, should be offered Essure removal surgery, after considering the patient specific risks for surgery.

Study objective: To compare laparoscopic Ablation and Excision in terms of symptom and Quality of Life outcomes as perceived by endometriosis patients.

Design: A Cohort, Method comparison Questionnaire-based study SETTING: Endometriosis-focused Social Media site PATIENTS: Endometriosis patients with history of Laparoscopic Ablation and Excision.

Interventions: On-line questionnaire focused on pre and post procedure (ablation and excision) outcomes across 63 measures in 5 realms: Physical Symptoms, Functional Impact, Psycho-emotional Impact, Social/Sexual Impact, Economic/Educational Impact.

Measurements and main results: 232 respondents with surgical history that included laparoscopic ablation and excision (without concomitant or interposed hysterectomy) identified for ablation only physical symptom improvement of 11.3% and 8.5% for dysmenorrhea and menorrhagia respectively. Ablation provided no significant improvement in any other physical symptom measure. Excision was identified as providing improvements across all symptoms ranging from 28% to 46%. In terms of Functional Impact, ablation provided non-significant improvements or worsening of status. Excision demonstrated significant improvement for patients across most measures of Functional Impact. In terms of Psycho-emotional Impact, a worsening of QoL status is identified in 23 of 24 measures following ablation. Excision demonstrated improvement in 22 of 24 measures. For Social-Sexual Impact, ablation resulted in worsened status across all measures with excision demonstrating improvements in all measures, significantly so in most. For Economic/Educational Impact, significant worsening of measures or insignificant improvements were demonstrated following ablation. Excision demonstrated significant improvement in most measures. In all realms, pre-Excision status was worse than pre-Ablation. Allowing for a more focused comparison of ablation and excision, 113 respondents with a surgical history of ablation sequentially followed by excision demonstrated outcomes similar to the larger group: overall worsening of status resulting from ablation and overall improvement in status following excision with pre-Excision morbidity higher than pre-Ablation.

Conclusion: In this cohort of patients undergoing laparoscopic endometriosis excision after having undergone endometriosis ablation, the former demonstrated greater beneficial effect over a broad spectrum of symptom and QoL measures.

Study objective: To assess the feasibility of percutaneous radiofrequency ablation (PRFA) of anterior abdominal wall endometriosis (AWE) lesions and to describe its efficacy on clinical symptoms and on the volume of the lesion.

Design: Interventional, prospective, non-comparative, phase 1 clinical trial.

Setting: Patients consulting at the multidisciplinary endometriosis expert center at Croix Rousse University Hospital (Hospices Civils de Lyon).

Patients: Ten patients with 1 to 3 AWE lesions treated by PRFA with 6 months follow-up.

Interventions: PRFA of AWE lesions were performed under ultrasound guidance. Initial power ranged from 3 to 10 W, with progressive increases in power. The thermal effect in the ablation zone was monitored in real time (appearance of hyperechoic signals). A contrast-enhanced ultrasound check was also carried out. We used multiShot technique until the entire nodule was covered by the hyperechogenic cloud.

Measurements and main results: Ten patients (12 nodules) were positively treated from 25/06/2020 to 27/07/2022, 8 under local anesthesia and 2 under general anesthesia, which represented 100% feasibility. Nine patients had previous caesarean section. At 6 months the nodule pain at palpation disappeared for 9 patients (90%), mean cyclic pain VAS significantly decreased from 5.7 points (0.9 SD 0.9 VS 6.6 SD 3.2 p=.03) and non-cyclic pain from 3.8 points (0.8 SD 1.3 vs 4.6 SD 3.3 p=.02). Patients reported a significant improvement of their quality of life at 6 months (SF36 total score increase by 218 points p<.01). We observed a significant reduction of 78% in the volume of the nodule at 6 months on MRI (1.2cm³ SD 1.3 vs 5.4cm³ SD 8.2 p<.01); 11/12 treated nodules were non-vascularized/enhanced on post-procedure MRI. All Patients were treated on an outpatient basis. We report one severe adverse event (incisional hernia).

Conclusion: PRFA is feasible and may be a clinically effective treatment for AWE. https://clinicaltrials.gov/study/NCT04333017 Clinical trial registry number: NCT04333017.

Objective: The evolution of nerve-sparing surgery has been supported by a growing body of literature on anatomic details, dissection techniques, and functional outcomes, suggesting that nerve-sparing surgery for deep endometriosis (DE) reduces postoperative pelvic organ dysfunction, including voiding and rectal dysfunction [1]. Recently, newer single-port robotic systems (da Vinci SP) have become available with articulating instruments and cameras that allow for intracorporeal triangulation, which may overcome some of the weaknesses of conventional single-port laparoscopic surgery [2]. Although such systems are believed to allow more complex surgeries than conventional single-port laparoscopic surgery, the scope of application remains unexplored. The objective of this video is therefore to demonstrate the anatomical and technical highlights of a complex intrapelvic procedure, nerve-sparing modified radical hysterectomy and complete removal of DE using the da Vinci SP (SP).

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

Participants: The patient was a 47-year-old woman who presented with chronic pelvic pain resistant to pharmacotherapy. Magnetic resonance imaging showed uterine adenomyosis and bilateral ovarian endometrioma with DE, involving the uterosacral ligament and surface of the rectum, with complete cul-de-sac obliteration.

Interventions: The surgical steps were completely identical to conventional multiport laparoscopic robotic surgery [3,4]. This suggests that conventional laparoscopic or robotic skills are highly transferrable to SP. SP offer several advantages, including high-resolution three-dimensional visualization, articulating instruments, and improved dexterity and range of motion. These advantages allow us to comfortably perform meticulous dissection and suturing even in difficult situations such as DE. The postoperative course was uneventful, with no perioperative complications, including no postoperative bladder or rectal dysfunction [5]. She was very satisfied with the invisible operative scar and low degree of postoperative pain.

Conclusion: Nerve-sparing eradication of DE using SP is technically safe and feasible, with cosmetic advantages and less pain.

Study objective: To evaluate clinical efficacy of office operative hysteroscopic treatment of retained products of conception (RPOC) without anesthesia.

Design: A retrospective cohort study.

Setting: A tertiary care academic medical center between April 2019 to March 2023.

Patients: A total of 175 patients with confirmed RPOC underwent see-and-treat operative office hysteroscopy without anesthesia in our outpatient clinic.

Interventions: Hysteroscopic removal of RPOC without anesthesia.

Measurements and main results: In 163 cases, the removal of RPOC in the office was attempted, and in 155 cases (95.1%), complete removal of the RPOC, without complications was achieved, although it sometimes required a second procedure in clinic. In 12 cases, office operative hysteroscopy was not attempted, due to physician decision based on the appearance and vascularity of RPOC, or due to pain during the diagnostic hysteroscopy, or both. The average size of RPOC for patients treated in the clinic was 15± 8.4 mm (range 4-47mm). One hundred twenty-eight cases were performed using a Truclear Elite 6mm device, and 35 cases using a mini-Bettocchi 4.2mm device. Eighteen cases were unsuccessful on the first attempt; 12 underwent a second procedure in the clinic, which was completed in 10 (83.3%) cases. 105 (71.4%) patients attended a follow-up hysteroscopy, eight of them (7.6%) required separation of adhesions that was performed in the clinic, and 8 patients were referred to a surgical procedure under anesthesia, due to persistent RPOC.

Conclusion: Operative office hysteroscopy is feasible and highly effective for patients with RPOC, with a total success rate of 95.1% complete evacuation in clinic. A follow-up hysteroscopy is important especially after treatment of large RPOC.

Study objective: This study aims to assess the prevalence of malignancy and other endometrial pathologies in asymptomatic postmenopausal women referred for office hysteroscopy (OH), identify main referral indications, and assess their relationship with the risk of malignancy. Secondary objectives included evaluating the association between ultrasound variables and malignancy risk and assessing procedure validity, which encompasses duration, feasibility, and patient comfort during OH.

Design: Retrospective analysis.

Setting: The study was conducted at the Department of Gynecology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Slovenia's largest tertiary care center.

Participants: The cohort consisted of 822 asymptomatic postmenopausal women referred for OH, excluding those with postmenopausal bleeding within the last year.

Interventions: Participants underwent OH with or without biopsy.

Measurements and main results: The main indication for hysteroscopy was ultrasound abnormalities alone, with remaining indications including a combination of ultrasound and clinical findings. Among the cohort, 97.4% exhibited benign findings, while 2.6% were diagnosed with cancer or precancerous lesions. The analysis revealed that patients with indications based on ultrasound and clinical findings suggestive of malignancy had a higher risk of malignancy compared to those with ultrasound alone. In 387 patients with documented ultrasound variables, inhomogeneous endometrial appearance (OR: 8.2, 95% CI: 2.4-27.9, p < .001) and significant liquid content within the uterine cavity (OR: 10.2, 95% CI: 3.6-28.9, p < .001) exhibited strong associations with malignancy. Analysis of the procedure revealed a high feasibility rate (87.8%), with a median duration of 13.7 minutes and a median Visual Analog Scale pain score after the procedure of 3/10.

Conclusion: The prevalence of endometrial cancer and precancerous lesions in asymptomatic postmenopausal patients is likely low, with most intrauterine pathologies being benign. Our study demises the utility of routine endometrial surveillance for this population in the absence of specific risk factors. A holistic approach, considering individualized assessments and factors beyond endometrial thickness, is crucial in interpreting ultrasonic findings.

Objective: Isolated fallopian tube torsion (IFTT) presents a challenging preoperative diagnosis. This study investigated the specific sonographic characteristics of IFTT and compared them to the characteristics of ovarian and adnexal torsion.

Design: Retrospective cohort study.

Setting: Tertiary level gynecological ultrasound unit.: 225 women operated for suspected isolated ovarian, fallopian tube or adnexal torsion (ovary and tube) were included.

Interventions: Electronic medical records of patients diagnosed with torsion at our ultrasound unit from 2001 to 2018 were retrieved. Inclusion criteria were women operated for suspicion of isolated ovarian, fallopian tube or adnexal torsion (involving both ovary and tube), with a preoperative sonogram performed in our tertiary level gynecologic ultrasound unit. Patients operated after a sonographic examination in the emergency department were excluded.

Measurements: Patients were divided into 4 groups according to their laparoscopic diagnosis: IFTT, ovarian torsion, adnexal torsion or no torsion. The sonographic characteristics of the groups were compared and the diagnosis was confirmed according to laparoscopy findings.

Main results: IFTT was reported in 28/225 (12.4%) cases. Ovarian volume was significantly lower in IFTT (29.2 ± 44 cm³⁾ compared to ovarian torsion (111 ± 143 cm³, p=.037). There were fewer cases of ovarian edema in IFTT compared to ovarian torsion (12/22 (54.5%) vs. 54/63 (85.7%) respectively, p=.001). IFTT was associated with paraovarian cyst significantly more often than with ovarian torsion (13/24 (54.2%) vs. 4/75 (5.3%), respectively; p=.003). There was no difference between whirlpool sign and location in all forms of torsion. The sensitivity, specificity, Positive predictive value and Negative predictive value for IFTT were 88.4%, 83.3%, 95.8% and 62% respectively.

Conclusion: IFTT has distinct sonographic characteristics, including normal ipsilateral ovary, paraovarian cyst, and whirlpool sign. Awareness of these features may improve the diagnosis of IFTT and promote faster and more efficient treatment. Further studies are needed to establish these characteristics.