Journal of minimally invasive gynecology最新文献

Objective: Transvaginal natural orifice transluminal endoscopic surgery(vNOTES) combines the benefits of traditional vaginal surgery-such as the absence of abdominal incisions, reduced postoperative pain, and improved cosmetic outcomes-with enhanced endoscopic visualization and working space compared to conventional vaginal instrumentation.^1-3This is particularly relevant in urogynecological surgery, where lower urinary tract injuries, especially bladder and ureteral damage, are among the most frequent complications.^4,5We present the feasibility and safety of performing high uterosacral ligament suspension(HUS) and bilateral adnexectomy via a vNOTES approach, with intraoperative ureteral visualization achieved using indocyanine green.

Design: Stepwise demonstration of the technique with narrated video footage.

Setting: A 63-year-old woman presenting with symptomatic pelvic organ prolapse(POP-Q: II Stage). Given that the patient presented with persistent and bothersome symptoms and an associated apical support defect, conservative management and isolated anterior repair were considered insufficient; therefore, an apical support procedure was selected to ensure durable anatomical and functional outcomes, and the proposed surgical management consisted of HUS with bilateral adnexectomy(upon patient's request), performed via vNOTES. The aims of the surgical approach and potential postoperative complications were clearly explained to the patient prior to obtaining informed consent.

Interventions: Firstly, a cystoscopy was performed, with bilateral ureteral injection of IGC at a concentration of 0.25 mg/mL, with a total volume of 3 mL per side. Then the GelPoint vPATH1 device(Applied Medicine, Rancho Santa Margarita, CA) was placed in the vagina and a low-pressure pneumoperitoneum was established. The uterosacral ligaments were identified by direct pulling. The suspension stitches are then placed crossing the uterosacral ligaments in their cranial part. Finally, a bilateral salpingo-oophorectomy was performed. The total operative time was 24 minutes, with minimal blood loss.

Conclusion: Determining the pelvic course of the ureters by transperitoneal ICG visualization was pivotal to avoid ureteral kinking during placement of the suspension sutures and to dynamically confirm ureteral patency following apical suspension. The vNOTES HUS with Real-Time ICG injection is technically feasible and allows clear and reliable identification of the uterosacral ligament. Our technique allows a good identification of mooring points for suspension, an improved vision of adjacent anatomical structures and avoiding any blindfold surgical maneuvers limiting the risk of ureteral injuries, making it a safer and more reproducible procedure.

Study objective: The development of uterine niche-also known as cesarean scar defect or isthmocele-is a potential long-term sequela after cesarean delivery, and may be associated with abnormal uterine bleeding, pelvic pain, and infertility. Previous literature examining prevalence consists of small cohort and case control studies. We aimed to calculate the incidence of uterine niche after primary cesarean delivery using a nationally representative database.

Design, settings, participants, intervention: Retrospective cohort study of individuals who underwent primary singleton cesarean delivery within the Vizient Clinical Database 2021-2024. Vizient is a healthcare performance improvement company that receives de-identified administrative and patient claims data.

Measurements: Niche cases were identified using International Classification of Diseases (ICD)-10 codes and imaging findings. The primary outcome was incidence of uterine niche, defined as number of cases of niche divided by the person-time-at-risk after primary cesarean delivery. Secondary outcomes included time to niche development and risk factors associated with niche.

Main results: Overall, 517,763 individuals underwent primary cesarean delivery during the study period. The mean age of the cohort was 32.7 years (SD 6.2) at primary cesarean delivery. There were 62,433 (12.1%) niche events over 915,842 person-years, resulting in an incidence rate of 68.2 events per 1,000 person-years after primary cesarean delivery (95% CI 67.6-68.7). Overall, 98.3% of niche cases developed after the first cesarean delivery. Mean time to diagnosis following primary cesarean delivery was 0.79 years (SD 0.58). Using multivariable logistic regression modeling, increased age, Back, Asian, or Hispanic race or ethnicity, history two or more deliveries, having non-commercial insurance, and history of tobacco use were associated with increased likelihood of developing a uterine niche.

Conclusion: The population incidence of uterine niche following cesarean delivery was 68.2 per 1,000 person-years, with mean time to diagnosis 0.79 years after primary cesarean. These data should inform complete counseling regarding the risks of cesarean delivery.

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.