Journal of minimally invasive gynecology最新文献

Objective: This systematic review and Bayesian network meta-analysis aimed to evaluate the comparative efficacy and safety of various laparoscopic techniques for endometrioma management, focusing on their impact on fertility outcomes and ovarian reserve preservation.

Data sources: A systematic search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, and Scopus, following PRISMA 2020 guidelines.

Methods of study selection: This systematic review and bayesian network meta-analysis included only randomized controlled trials (RCTs), encompassing women between 18 and 45 years, undergoing primary laparoscopic surgery for unilateral or bilateral endometriomas. Eligible interventions included cystectomy with bipolar coagulation, cystectomy alone, cystectomy with suturing, fenestration with bipolar coagulation, drainage with CO₂ laser vaporization, cystectomy with hemostatic sealant, cystectomy with ultrasonic scalpel, and vasopressin-assisted cystectomy with bipolar coagulation. Eleven RCTs were included (956 participants).

Tabulation, integration, and results: Statistical analyses integrated Bayesian random-effects to compute pooled risk ratios (RR), and mean differences (MD), with 95% credible intervals (Crls). SUCRA rankings were used to rank interventions. For cumulative pregnancy rate within 12 months (Δ AMH at 3, 6 and 12 months), no statistically significant differences were observed across treatment comparisons. However, probabilistic ranking consistently indicated cystectomy with ultrasonic scalpel as the most favorable technique at 6 (SUCRA=0.711) and 12 months (SUCRA=0.693), while cystectomy with suturing ranked the least favorable. Regarding reproductive outcomes, drainage with CO₂ laser vaporization showed the most favorable ranking profile for cumulative clinical pregnancy within 12 months. Importantly, the overall ranking probabilities for fertility and ovarian reserve were not supported by statistically significant differences among techniques.

Conclusion: This meta-analysis evaluated different laparoscopic techniques for endometrioma management. While no technique demonstrated statistically significant superiority across all outcomes, the probabilistic rankings identified cystectomy with ultrasonic scalpel as a more favorable approach for ovarian reserve preservation and drainage with CO₂ laser vaporization for pregnancy achievement. These findings highlight the need for careful, individualized patient counseling enabling tailored surgical decisions aligned with individual reproductive goals. Future direct head-to-head trials with standardized long-term follow-up are warranted to definitively guide clinical practice.

Objective: To describe a multiple-steps hysteroscopic approach to restore normal uterine anatomy in a patient presenting with single cervix, partial cervical septum, complete uterine septum, and 4 cm intraseptal fibroid. Uterine septum is the most common congenital anomaly of the female genital tract¹. Its association with septate cervix is rare². In exceptional cases, a fibroid may be found within the uterine septum. Published video demonstrations of intraseptal fibroid management are limited.

Setting: The procedures were performed at the Digital Hysteroscopic Clinic CLASS-Hysteroscopy of Fondazione Policlinico Gemelli-IRCCS in Rome, Italy.

Participants: A 37-year-old infertile woman with cervical septum and complete uterine septum complicated by G2 intraseptal fibroid³ protruding into the left uterine hemi-cavity. A diagnostic approach, combining 2D/3D transvaginal ultrasound (TVUS) and office hysteroscopy, followed by magnetic resonance imaging prior to surgery were performed⁴. IRB approval was obtained.

Interventions: A three-steps hysteroscopic approach under anesthesia with laryngeal mask was performed, according to an ambulatory model of care⁵. The first step involved the incision of the cervical septum and partial incision of the uterine septum until the fibroid plane, using the Collins loop of a 15-Fr bipolar mini-resectoscope, followed by the first step of myomectomy with a 90°-angled-loop of a 26-Fr bipolar resectoscope. The second step was performed one month later to complete the myomectomy. The third procedure was carried out one month after the second step, to remove the uterine septum using a 15-Fr bipolar mini-resectoscope. No complications occurred. The patient was discharged three hours after each procedure. Post-operative hysteroscopic control revealed a normal cervix and a normally shaped uterine cavity, with no intrauterine adhesions or residual fibroid tissue.

Conclusion: The integration of 2D/3D TVUS and hysteroscopy, in the hands of experienced and skilled surgeons, is essential for managing rare and complex cases, minimizing complications and ensuring optimal surgical outcomes.

Study objective: To demonstrate a reproducible approach to the laparoscopic excision of endometriosis involving the obturator nerve.

Design: Narrated surgical video.

Setting: Academic tertiary care hospital.

Participants: Case of a 30-year-old woman found on MRI to have a 1.6 cm endometriosis nodule involving the left obturator nerve, along with adenomyosis, rectovaginal and ureteric endometriosis. Due to symptoms refractory to medical management, a laparoscopy is performed to excise the obturator nerve lesion, in addition to a disc rectal excision and ureteral reimplantation.

Interventions: Laparoscopic excision of obturator nerve endometriosis.

Measurements and primary results: The surgical steps can be summarized in six steps: (1) abdominal survey; (2) sigmoid mobilization; (3) iliolumbar space(lateral) dissection; (4) pararectal space (medial) dissection; (5) obturator space (caudal) dissection; (6) nodule release and excision.

Conclusion: Excision of obturator nerve endometriosis by laparoscopy can be safely performed with a thorough knowledge of anatomy and a systematic dissection of pelvic spaces. MRI is essential for preoperative planning in these rare forms of deep infiltrating endometriosis.

Objective: To develop and validate preoperative nomograms for predicting pediatric adnexal torsion (AT) and post-torsion adnexal necrosis using clinical, laboratory, and ultrasonographic parameters.

Design: Retrospective cohort study.

Setting: Single-center medical institution (Tianjin Children's Hospital).

Participants: A total of 186 girls (≤18 years) with suspected AT who underwent surgical exploration between March 2019 and January 2025.

Interventions: Patients were randomly divided into training (n=130) and test (n=56) cohorts. Candidate variables including demographic characteristics, symptoms, laboratory indices, and ultrasound findings were screened using least absolute shrinkage and selection operator (LASSO) regression. Multivariable logistic regression models were constructed to predict AT and, among confirmed AT cases, adnexal necrosis. Model performance was evaluated by area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis.

Results: Adnexal torsion was confirmed in 67 patients (36.0%), of whom 21 (31.3%) had pathological adnexal necrosis. For AT prediction, age, abdominal tenderness, systemic immune-inflammation index (SII), and the ultrasonographic whirlpool sign were identified as independent predictors and incorporated into a nomogram. This model demonstrated good discrimination (AUC 0.933 in the training cohort and 0.891 in the test cohort) with satisfactory calibration. Among patients with confirmed AT, pan-immune-inflammation value (PIV) and thrombin time (TT) independently predicted adnexal necrosis and were used to construct a separate necrosis nomogram, achieving an AUC of 0.811. Both models provided favorable net clinical benefit across clinically relevant threshold probabilities.

Conclusion: These nomograms provide a clinically accessible framework for preoperative risk stratification of pediatric AT and adnexal necrosis, leveraging routine clinical, laboratory, ultrasonographic, and emerging inflammatory indices.

Study objective: To investigate the areas of greatest hand pain among laparoscopic gynecologic surgeons and to analyze surgeon variables associated with discomfort.

Design: Secondary analysis of observational cohort survey data.

Setting: United States nationwide survey PATIENTS: Gynecologic surgeons were surveyed via email through the Society of Gynecologic Surgeons and a convenience sample of U.S. academic institutions.

Interventions: Surgeons reported demographic characteristics, presence of hand pain in specific locations, and use of laparoscopic advanced energy devices.

Measurements & main results: Of 190 participants, a majority (68.9%) reported discomfort attributed to laparoscopy; over half (56.8%) reported hand pain. Prevalence of pain in the thumb, forefinger, and wrist was greater among surgeons of female sex, glove size <7, and trainee status. After adjustment for glove size, residents had increased odds of pain in the thumb (aOR 4.18, CI 1.82-10.81), forefinger (aOR 4.16, CI 1.24-13.92) and wrist (aOR 4.47, CI 1.60-12.53) compared to attendings with >10 years of experience. Surgeons of glove size <7 had increased odds of pain in the thumb (aOR 2.23, CI 1.10-4.52), forefinger (aOR 3.03, CI 1.16-7.96), and wrist (aOR 2.53, CI 1.15-5.58) after adjustment for level of experience. Among LigaSure users, residents more often endorsed pain at each hand site and reported the LigaSure device as too large (71.4%) compared to fellows and attendings (p=0.012).

Conclusion: Hand pain is highly prevalent among gynecologic laparoscopists. Surgeons of smaller glove size had over two times and residents had over four times the odds of hand pain with laparoscopy. Prioritization of surgical ergonomics education among trainees and the development of ergonomic laparoscopic tools remains critical, as does research on surgeon real-time experiences to eliminate the self-selection bias inherent in survey-based research.