Journal of minimally invasive gynecology最新文献

Study objective: This study aims to evaluate a liberal postoperative voiding policy after minimally invasive hysterectomies to assess the impact of length of stay in the postoperative care unit (PACU).

Design: This is a retrospective interrupted time series study. Patients were identified 3 months before and after the policy change, and a chart review was conducted of medical records. The study was powered to detect a difference of 60 minutes between the pre- and post-policy groups. Secondary outcomes included post operative urinary retention (POUR), postoperative readmission and urinary tract infections (UTI). Wilcoxon rank-sum tests and Fisher's exact tests were utilized to compare outcomes between the pre- and post-policy groups.

Setting: All surgeries were completed within the division of Minimally Invasive Gynecologic Surgery at a single academic institution.

Participants: Female patients aged 18 and older were included if they had undergone a minimally-invasive hysterectomy for benign indications between August 17, 2022 and February 17, 2023. Exclusion criteria included surgery for gynecologic cancer, concurrent incontinence or pelvic floor surgeries, or if patients had a history of urinary retention or bladder surgery.

Intervention: A new liberal voiding protocol that did not require patients to void prior to discharge.

Measurements and main results: 65 patients were identified for the pre-policy group, and 54 in the post-policy group. There was insufficient evidence to detect a difference in PACU length of stay (median 302 minutes pre vs 250 minutes post) or incidence of POUR or UTIs.

Conclusion: The study concluded that a liberal voiding protocol is a feasible policy change. Although there was no statistically significant difference in the PACU length of stay, there was a trend toward decreased length of stay as the median was lower for this group. The results point toward a liberal voiding policy being safe, without changes seen in rates of POUR or UTIs.

Objective: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is utilised for gynecological procedures globally, however evidence to support its application aside from hysterectomy is lacking. A systematic review to determine feasibility and safety profile of vNOTES for benign gynaecology was conducted.

Data sources: A literature search of MEDLINE, EMBASE, CINAHL, SCOPUS, and CENTRAL was conducted, including all types of studies reporting vNOTES for gynecological indications. After excluding cases with concurrent hysterectomy, the review focuses on procedures for benign indications and oncological procedures are reported separately. Patient characteristics and perioperative outcomes were reported, with pooled analysis for sufficiently powered categories.

Methods of study selection: Fifty-four articles were analyzed, including 7 comparative studies (n = 439) and 1 RCT (n = 34), reporting 2469 cases of vNOTES, including adnexal (tubal and/or ovarian) (43 articles, n = 2261), myomectomy (10 articles, n = 136) and prolapse repair (6 articles, n = 72) in predominantly premenopausal women with BMI <30 kg/m² on pooled analysis.

Tabulation, integration and results: The overall conversion rate was low (1.38%, n = 34) with procedure specific conversion rates of 0.45 to 6.8% for adnexal procedures, 1.47% for myomectomy and none reported for prolapse repair. Overall complication rates were low (3.44%, n = 85) with no associated mortality. Five (0.20%) adhesion-related rectal injuries at colpotomy were noted, all repaired intraoperatively without long-term sequelae.

Conclusion: vNOTES appears feasible based on limited evidence, for uterine-sparing gynecological indications, despite a notable rate of rectal injury at colpotomy. There is a negligible risk of rectal injury observed at conventional laparoscopy and robotically assisted surgery, but similar rate of entry-related gastrointestinal injury. This may be due to the learning-curve or suboptimal case selection, necessitating careful training, assessment, and appropriate patient selection. Surgeons should continue registering prospective vNOTES cases via iNOTESs, to evaluate emerging perioperative trends with global uptake of this novel technique.

Objective: Comparison of the clinical efficacy of hysteroscopic subendometrial injection of platelet-rich plasma (PRP) and intrauterine instillation of PRP for the treatment of intrauterine adhesions.

Design: A Retrospective Cohort Study.

Setting: University hospital.

Patients: Patients who underwent hysteroscopic transcervical excision of adhesions from September 1, 2020, to July 31, 2023, and were treated with PRP in the postoperative period were included.

Interventions: Subendometrial PRP injection group (referred to as SE-PRP group) and intrauterine PRP infusion group (referred to as IU-PRP group) MEASURES AND MAIN RESULTS: A total of 299 patients with moderate-to-severe IUA treated with PRP after Transcervical resection of adhesions (TCRA) were included. The primary outcome metric was the clinical pregnancy rate, and the secondary outcome metrics were the rate of menstrual improvement and the AFS score. The results showed that: the AFS reduction scores was greater in the SE-PRP group than in the IU-PRP group (8 vs 7, p = 0.019); the menstrual improvement rate in the SE-PRP group was higher than that in the IU-PRP group (77.0% vs 52.9%, p < 0.001); and the clinical pregnancy rate in the SE-PRP group was similar than that in the clinical pregnancy rate in the IU-PRP group (28.4% vs 20.4%, p = 0.208). The results of multifactorial logistic regression analysis showed that the clinical pregnancy rate in the SE-PRP group was significantly higher than that in the IU-PRP group (OR = 2.020, 95% CI = 1.050-3.889, p = 0.035). The results of the propensity score matching (PSM) analysis showed that: the median postoperative AFS score reduction was significantly higher in the SE-PRP group than in the IU-PRP group (p = 0.015); and the rate of improvement in menstruation was significantly higher in the matched SE-PRP group (75.0% vs 58.1%, p = 0.027) and clinical pregnancy rates were higher in the SE-PRP group (29.4% vs 16.2%, p = 0.043).

Conclusions: Hysteroscopic intrauterine PRP injection is more clinically effective than intrauterine PRP infusion for patients with moderate to severe intrauterine adhesions, resulting in greater reduction in adhesion scores, improvement in menstrual rate, and increased clinical pregnancy rate.

Study objective: To compare surgical outcomes among patients undergoing minimally invasive myomectomy (MIM) or abdominal myomectomy (AM) with MIGS subspecialists versus general obstetrician/gynecologists (OB/GYNs), and to characterize the complexity of myomectomies by surgeon type.

Design: Retrospective cohort study.

Setting: Quaternary care institution.

Participants: Patients who underwent MIM (laparoscopic or robotic) or AM with a fellowship-trained MIGS subspecialist or general OB/GYN from March 15, 2015 to March 14, 2020.

Interventions: Myomectomy.

Results: Of 609 myomectomies, 460 (75.5%) were MIM, 404 (87.8%) of which were performed by MIGS subspecialists. The remaining 149 (24.5%) cases were AM, 36 (24.1%) of which were performed by MIGS subspecialists. Compared to general OB/GYNs, MIGS subspecialists excised a greater number of fibroids for both MIM (median 3.0 [range 1.0-30.0] vs 2.0 [1.0-9.0], p <.001) and AM (21.0 [10.0-60.0] vs 6.0 [1.0-42.0], p <.001), and had a greater proportion of uteri >20 weeks size for AM (22.2% vs 3.5%, p = .003). Composite perioperative complication rates were significantly higher for general OB/GYNs than for MIGS subspecialists (29.0% vs 11.8%, adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 1.48-4.92). In a subgroup analysis of MIM only, general OB/GYNs had higher rates of composite perioperative complications (28.6% vs 9.9%, aOR 4.51, 95% CI 2.27-8.97), excessive blood loss and/or transfusion (10.7% vs 3.0%, unadjusted odds ratio [OR] 3.92, 95% CI 1.41-10.91), surgery time ≥ 90th percentile (25.0% vs 8.9%, aOR 5.05, 95% CI 2.39-10.64), and conversions to laparotomy (10.7% vs 0.2%, unadjusted OR 48.36, 95% CI 5.71-409.93). For AM only, there were no significant differences in perioperative complication rates between groups.

Conclusion: Fellowship-trained MIGS subspecialists had improved surgical outcomes for MIM compared to general OB/GYNs, with fewer conversions to laparotomy, reduced surgery time, and less blood loss, while outcomes for AM were similar by surgeon type. MIGS subspecialists excised a greater number of fibroids regardless of surgical approach, highlighting a level of comfort in complex benign gynecology beyond endoscopic surgery at our institution.

Objective: To demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages.

Design: Retrospective case series.

Setting: Single academic tertiary care hospital in Houston, Texas, USA.

Participants: Twenty-eight adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection.

Interventions: Hysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform).

Main results: Twenty-eight patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m² (range 19.5-48.4 kg/m²), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0 mL). One case required a mini-laparotomy as the irregularly shaped 1668 g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection.

Conclusion: Our findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries.

Objective: To evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection.

Data sources: A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: April 30, 2024).

Methods of study selection: We included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials, observational prospective or retrospective studies, and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included.

Tabulation, integration, and results: Nine studies, including 574 women affected by DIE and submitted to urodynamic assessment, were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% confidence interval [CI] 3, 26; I2 = 93.9%, p <.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2 = 78.1%, p <.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2 = 97.2%, p <.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2 = 86%, p <.001), low preoperative bladder compliance was reported in 35% of patients (95% CI 30, 40; I2 = 0%, p = .66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2 = 0%, p = .58). No difference between preoperative and postoperative UDS detrusor overactivity was reported (odds ratio [OR] 0.45; 95% CI -0.10, 1.0, I2 = 0%; p = .66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2 = 49.6%; p = .12).

Conclusion: Abnormal urodynamic findings before surgery are prevalent in women with DIE. Surgery seems not to affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings.

Study objective: To demonstrate a safe and reproducible surgical approach to the Alcock canal with a full decompression of the pudendal nerve.

Design: The technique is demonstrated step-by-step with narrated video footage.

Setting: Pudendal neuralgia, a condition causing debilitating pelvic pain, is traditionally managed through a transgluteal incision [1,2]. This surgical approach offers limited visualization and ability for nerve decompression [3]. With the current technique, a full exposure and decompression of the pudendal nerve was achieved.

Interventions: A 44-year-old para 2 presented with burning vaginal pain radiating to the left groin that was aggravated with sitting. She underwent a robotic-assisted left sacrospinous ligament transection and fasciotomy of the obturator internus muscle for suspected pudendal neuralgia. The surgery was performed with 3 robotic ports using the da Vinci Xi robotic system.

Conclusion: With the enhanced access to the pudendal nerve provided by the novel surgical technique demonstrated in this study, a more comprehensive nerve decompression can be performed. This technique was successfully applied to a patient with pudendal neuralgia. There were no immediate intra- or postoperative complications. In short-term follow-up, the patient had significant relief of preoperative symptoms. Although all surgical procedures for pudendal neuralgia have a risk of pudendal nerve and vessel injury [4], the presented technique has the potential to limit these risks by providing an enhanced view of the relevant anatomy. Future adaptation and refinement of this technique may contribute to the advancement of the surgical management of pudendal neuralgia. VIDEO ABSTRACT.

Study objective: Vaginal packing is traditionally placed after pelvic floor reconstructive surgery (PFRS) to prevent hematoma formation. We seek to determine if there is a difference in postoperative pain scores after PFRS if vaginal packing is soaked with estrogen cream, bupivacaine, or saline. The primary outcome was pain as measured by a visual analog scale at 2 hours, 6 hours, and 1 day postoperatively. Secondary outcomes include changes in hemoglobin, urinary retention and length of stay (LOS) in hospital.

Design: Prospective cohort study.

Setting: Tertiary care academic teaching hospital. All PFRS is performed by fellowship-trained urogynecologists.

Participants: Consenting patients undergoing PFRS.

Interventions: At the completion of surgery, gauze packing soaked with either estrogen cream, 0.25% bupivacaine with 1% epinephrine, or normal saline was placed inside the vagina and removed on postoperative day 1.

Measurements and main results: We included 210 patients (74 estrogen, 66 bupivacaine, 70 saline). There was no significant difference in mean postoperative pain scores between the groups (estrogen, bupivacaine, saline-soaked vaginal packs respectively) at 2 hours (2.66 ± 2.25, 2.30 ± 2.17, 2.24 ± 2.07; p = .4656), 6 hours (2.99 ± 2.38, 2.52 ± 2.30, 2.36 ± 2.01; p = .2181) or on postoperative day 1 (1.89 ± 2.01 vs 2.08 ± 2.15 vs 2.44 ± 2.19; p = .2832) as measured by visual analog scale scores (0-10). There was no difference in the secondary outcomes of change in pre/postoperative hemoglobin (21.8 ± 10.73g/L, 20.09 ± 11.55 g/L, 21.7 ± 9.62g/L, p = .68), urinary retention (37%, 45% and 48%, p = .45), LOS (1.05 ± 0.46 days, 1.02 ± 0.12, 1.03 ± 0.24, p = .97) or in-hospital opioid usage during admission (represented in morphine milligram equivalents [median (IQR1, IQR3)], Kruskal-Wallis test): 11.25 mg (0, 33), 7.5 mg (0, 22.5) and 15 mg (0, 33.88) p = .41.

Conclusion: There was no difference found between soaking vaginal packing with estrogen cream, bupivacaine, or saline after PFRS with respect to postoperative pain scores, LOS, in-hospital opioid usage, or urinary retention. Saline-soaked packing is an equivalent alternative to estrogen or bupivacaine vaginal packing.

Objective: To compare characteristics of Urogynecology training and number of "Incontinence and Pelvic Floor" cases logged between Obstetrics and Gynecology (OB/GYN) residencies affiliated and those not affiliated with Urogynecology fellowships.

Design: A retrospective descriptive analysis was performed of OB/GYN residency programs, their Urogynecology training, and association with Urogynecology fellowship programs during the 2023 to 2024 academic year. Program websites for Accreditation Council for Graduate Medical Education (ACGME)-accredited OB/GYN residency programs were reviewed to determine availability, timing, and length of Urogynecology training. ACGME data for "Incontinence and Pelvic Floor" cases were analyzed by training year and association with Urogynecology fellowship programs from the 2012-2013 to 2022-2023 academic year. Data was analyzed using SPSS.

Setting: This research was conducted at Harbor-UCLA Medical Center.

Participants: None.

Interventions: None.

Results: Information was obtained for 85.9% of programs. Nearly all (97.0%) had dedicated Urogynecology rotations, and 64.4% had rotations in >1 year of training. Association with Urogynecology fellowship did not affect the availability of Urogynecology training overall nor the overall number of rotations. Urogynecology rotations occurred most often in the third (PGY3) year of residency, though 43.6% of programs had training for junior (PGY1, PGY2) residents. Residencies with associated Urogynecology fellowships were more likely to have a rotation for PGY2 residents and for junior residents overall. From 2012 to 2023, the number of "Incontinence and Pelvic Floor" cases declined by 36.3%, with trainees at residencies not affiliated with Urogynecology fellowships logging more cases than those at a fellowship-affiliated residency.

Conclusion: While the majority of OB/GYN residencies have dedicated Urogynecology training, most rotations are for senior residents. Training programs associated with Urogynecology fellowships are more likely to expose junior residents to the field, but their trainees log fewer "Incontinence and Pelvic Floor" cases overall. Earlier exposure may enrich surgical training and help residents prepare for their careers, whether in Urogynecology or as a generalist.