Journal of minimally invasive gynecology最新文献

Study objective: To evaluate the predictive value of preoperative triple pelvic examination combined with transvaginal sonography (TVS) for posterior pelvic deep endometriosis (DE).

Design: A prospective randomized controlled clinical study comparing preoperative and intraoperative Enzian scores.

Setting: the Affiliated Hospital of Qingdao University.

Patients: Eighty-five patients who underwent surgical treatment for endometriosis between June 2022 and December 2024.

Interventions: Patients were randomized into two groups: Group A (n = 42) underwent TVS and triple pelvic examination separately and independently; Group B (n = 43) had TVS with prior provision of triple pelvic examination findings to sonographers. Preoperative Enzian scoring integrated clinical and TVS findings, and intraoperative Enzian scores were recorded.

Measurements and main results: In both Group A and Group B,the triple pelvic examination demonstrated significantly higher sensitivity than TVS for detecting USL lesions (P = 0.002 and P = 0.049, respectively). In contrast, TVS was markedly superior to the triple pelvic examination in diagnosing DE lesions in the POD (P = 0.001 and P = 0.049, respectively). The combination of the triple pelvic examination and TVS improved both the sensitivity and accuracy for detecting deep pelvic endometriotic lesions, particularly for USL involvement (P = 0.002 and P = 0.049, respectively). For USL lesions, the sensitivity of TVS performed after clinical examination in Group B was 68.18%, which was significantly higher than the 38.10% achieved by TVS alone in Group A (P = 0.023).

Conclusion: Combining TVS with triple pelvic examination for preoperative Enzian scoring improves the sensitivity of posterior pelvic DE detection, with complementary advantages at different lesion sites.

Study objective: Adverse surgeon stress can contribute to poor non-technical skills and burnout, impacting surgical performance and patient outcomes. Identifying surgical stressors is key to improving surgeons' and patients' wellbeing. We aim to describe biological measures of surgeon stress during laparoscopic exercises.

Design: Prospective Cohort SETTING: Simulated laparoscopic exercises were completed in an isolated research setting.

Patients: 26 Surgeon volunteers INTERVENTIONS: Participants completed peg transfer, pattern cutting, and intra-corporal knot exercises from the fundamental laparoscopic skills curriculum in neutral and stressed (ergonomic, time pressure, or noise) conditions. Measures of cortisol, HR, and HRV were recorded at baseline and during simulation and NASA task load Index (TLX) post simulation.

Measurements and main results: 26 surgeons participated, with wide variation in biological response to laparoscopic exercises. Surgeons' mean scores from baseline decreased for cortisol (10.1 vs. 7.2nmol/L), increased for mean and maximum heart rate (79.2 vs. 88.6bpm; 95.8 vs. 109.0bpm), and were unchanged for HRV. Proportionally, 22% of surgeon-simulations recorded increased cortisol, 79% increased maximum HR, 42% increased HRV low-frequency to high frequency ratio, and 70% increased HRV standard deviation of beat-to-beat. Mean HR was higher during "neutral" exercises relative to "stressed" exercises, however a greater proportion of HRV measures were higher in "stressed" exercises. Changes in HR were not significantly correlated with physical dimensions of NASA-TLX.

Conclusion: This study demonstrates current biological measures are widely variable within and between individuals. Overall, the discriminatory capacity of these measures for stress detection and tracking when using pooled means is poor.

Study objective: To evaluate the effectiveness of intraoperative proctosigmoidoscopy in patients undergoing bowel endometriosis surgery DESIGN: Retrospective, single-centre observational study.

Setting: Department of Gynecology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India PATIENTS: Patients undergoing bowel endometriosis surgery and intraoperative proctosigmoidoscopy at the end of the intervention, from April 2022 to March 2025.

Interventions: Description of findings at intraoperative proctosigmoidoscopy after bowel endometriosis resection.

Measurements and main results: Among 300 endometriosis surgeries, 126 involved bowel lesions: 100 partial thickness discoid excisions/shaving, 18 full thickness discoid excision, and 8 segmental bowel resections. This study reports on the latter 2 groups (26 patients in total) who also underwent intraoperative proctosigmoidoscopy. In these 26 patients, findings included 1 case each of bleeding and leak at the anastomosis site (bleed identified only on proctosigmoidoscopy). Postoperatively, 4 patients reported persistent constipation, and another 2 had chronic pelvic pain. No rectovaginal fistulas or luminal narrowing or dyschezia/dyspareunia were observed.

Conclusions: Intraoperative proctosigmoidoscopy is a feasible and valuable adjunct to endometriosis surgery involving the bowel. It may refine intraoperative decision-making and has the potential reduce both short- and long-term complications.

Objective: To demonstrate selective reduction of a heterotopic cesarean scar pregnancy with hysteroscopy while preserving a concurrent intrauterine pregnancy.

Design: Single case report demonstrating stepwise hysteroscopic technique to manage heterotopic pregnancy through narrated surgical video INTRODUCTION: Cesarean scar pregnancies occur in approximately 1 in 2,000 pregnancies, and the incidence of a cesarean scar pregnancy occurring concurrently with an intrauterine pregnancy is unknown (1,2). Cesarean scar pregnancies carry a high risk of uterine rupture and massive hemorrhage; therefore, early diagnosis and intervention is critical (1,2). In our case, transvaginal ultrasound demonstrated an intrauterine pregnancy of 5 weeks and 0 days with cardiac activity and a cesarean scar pregnancy consisting of a gestational sac measuring 5 weeks located 3.3 cm from the fundal pregnancy with 4.3 mm of overlying myometrium, consistent with a type I CSP (3,4). Review of the literature, including a study by Ouyang et al., identified 12 similar cases, four of which were managed using hysteroscopy alone or hysteroscopy combined with additional surgical techniques (5).

Interventions: Under intraoperative ultrasound guidance using sagittal views, a 27F operative bipolar hysteroscope was utilized with normal saline as the distension medium. Intrauterine pressure was maintained at or below 60 mmHg, with a final fluid deficit of 750 mL. Complete selective reduction of the cesarean scar pregnancy was confirmed at the conclusion of the procedure using transverse and sagittal ultrasound views.

Conclusion: We report a case of a 41-year-old G3P2001 with two prior cesarean deliveries who developed a fundal intrauterine pregnancy and a cesarean scar pregnancy after two-embryo IVF transfer. Surgical management with a loop bipolar hysteroscopic system resulted in successful selective reduction of the cesarean scar pregnancy and preservation of the concurrent intrauterine fundal pregnancy.

Objective: To systematically evaluate the clinical evidence on intraoperative navigation techniques in endometriosis surgery.

Data sources: In accordance with the PRISMA guidelines, a systematic literature search was conducted in the databases PubMed/MEDLINE, Embase, and Scopus covering the period from 2015 to 2025, with the final search performed on September 10th, 2025. In addition, an AI-assisted platform was used as a complementary search tool to identify further relevant literature.

Methods of study selection: Eligible studies comprised surgical studies in humans reporting intraoperative navigation techniques. Preclinical and cadaveric studies, reports without intraoperative applications, and interventions lacking a navigation component were excluded. Abstracts were excluded unless intraoperative data were extractable. Only English-language publications were included, with no restrictions on study design. Study selection was conducted by two independent reviewers followed by full-text assessment, with discrepancies resolved by consensus.

Tabulation, integration, and results: A standardized template captured design, sample size, navigation modality, technical parameters, approach, workflow integration, and outcomes; quality appraisal used design-specific tools. From 800 records, 54 studies (1,002 patients) met inclusion criteria: 41 intraoperative optical imaging studies (IOI) (976 patients), 12 intraoperative ultrasound studies (IOUS) (24 patients), and 1 augmented/virtual reality (AR/VR) case series (2 patients). IOI mainly supported anatomic orientation, lesion assessment, and perfusion-related decisions; IOUS supported lesion localization and landmark definition; AR/VR supported preoperative 3D planning which was used intraoperatively.

Conclusion: In endometriosis surgery, IOI, particularly indocyanine green-guided surgery, and IOUS currently constitute the predominant reported navigation modalities, supporting real-time anatomical orientation and informed intraoperative decision-making in complex pelvic disease, while AR/VR applications remain at an early stage of clinical translation. Despite the challenging pelvic anatomy and heterogenous disease manifestations that could benefit from intraoperative navigation, current evidence remains limited. Prospective comparative studies are needed to define clinical indications and to determine the added value of these technologies.

Objective: To identify clinical and demographic predictors associated with placing high value on the uterus among women with gynecological conditions in the United States.

Design: Multicenter cross-sectional survey study utilizing the validated Value of the Uterus (VALUS) instrument and visual analog scale (VAS) to assess uterine value perceptions.

Setting: Eleven medical centers across four U.S. regions (South, Southwest, West, and Northeast) from December 2023 to June 2024.

Participants: Participants included adult patients with a uterus, assigned female sex at birth, and not considering future pregnancies. Of 906 surveys distributed, 714 completed surveys (79% response rate) were analyzed. Most participants identified as White (74.9%), were 45-60 years old (36%), and postmenopausal (55.3%). Regional distribution included South (35.6%), West (34.7%), Northeast (22%), and Southwest (4.3%).

Interventions: Participants completed surveys assessing demographics, clinical history, the VALUS instrument (range 6-30), and a VAS question rating importance of uterine preservation (0-100 scale). Participants were stratified using median VALUS score of 16 as the cut-off: 336 (47%) had low uterine value (VALUS <16) and 378 (53%) had high uterine value (VALUS ≥16).

Results: The mean VAS score was 40.8 (SD: 32.4). Multivariable logistic regression, controlling for income, age, and urinary incontinence (UI), revealed significant predictors of high uterine value. Asian American/Pacific Islander (AAPI) individuals had higher odds compared to White individuals (adjusted OR=2.34; 95% CI 1.24-4.60; p=0.01). Annual income of $20,000-$49,000 was associated with higher odds versus the highest income bracket (adjusted OR=2.53; 95% CI 1.49-4.36; p<0.01). Self-reported UI was associated with lower odds of high uterine value (adjusted OR=0.71; 95% CI 0.51-0.97; p=0.03).

Conclusion: AAPI racial identity, lower income, and absence of UI predict placing high value on the uterus. Clinicians should incorporate these factors into shared decision-making when counseling patients regarding hysterectomy versus uterine-preserving procedures.

Objective: To describe a safe and efficient approach for robotic myomectomy using the Hugo™ RAS system, emphasizing aesthetic trocar positioning, optimized hemostatic strategies, and precise uterine reconstruction in a fertility-preserving setting.

Setting: Referral center (Einstein Hospital Israelita, São Paulo, Brazil), with active use of the Hugo™ RAS platform in gynecologic surgery.

Participants: A 41-year-old nulliparous woman with abnormal uterine bleeding and infertility, desiring future fertility. Magnetic resonance imaging revealed an enlarged uterus (202 cm³) with multiple fibroids. The dominant lesion was a 5.5-cm FIGO type 2 anterior fibroid. Smaller fibroids did not distort the uterine cavity and were not removed to avoid unnecessary myometrial injury.

Interventions: Robotic myomectomy was performed using three robotic arms and standard laparoscopic trocars, as the system does not require proprietary ports. (1) The approach was selected based on favorable fibroid size and location. Although robotic assistance is not indispensable, it may facilitate precise multilayer suturing and effective hemostatic control in fertility-preserving surgery. Low abdominal port placement was adopted for improved cosmetic results, acknowledging that this configuration may not be suitable for larger uteri. Hemostasis included temporary bilateral uterine artery clipping and intramyometrial vasopressin injection. Monopolar and bipolar energy were used. Specimen extraction was performed transvaginally using a protective bag; alternative contained cold-scalpel morcellation techniques may be considered in selected nulliparous patients. Operative time was 122 minutes, with 50 mL estimated blood loss and no complications. (2) CONCLUSION: Robotic myomectomy with the Hugo™ RAS platform demonstrated feasible and safe performance in this selected case. There are currently no comparative studies supporting superiority over other robotic systems.

Objective: To describe a minimally invasive hysteroscopic approach for the diagnosis and treatment of Robert's uterus, a rare congenital uterine anomaly characterized by a septate uterus with a non-communicating hemicavity, tipically presenting as a blind uterine horn with unilateral hematometra, a contralateral unicornuate uterine cavity, and a normally shaped external uterine profile.

Setting: Digital Hysteroscopic Clinic - CLASS Hysteroscopy, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.

Participants: A 30-year-old woman with symptomatic obstructed müllerian anomaly diagnosed as Robert's uterus.

Interventions: A one-stop hysteroscopic approach was performed in a single session, combining two-dimensional (2D) transvaginal ultrasound with three-dimensional (3D) reconstruction of the uterine anatomy, followed by diagnostic hysteroscopy using a 5 mm hysteroscope, thus avoiding the need for magnetic resonance imaging (MRI). This integrated 3D ultrasound and hysteroscopic assessment enabled definitive diagnosis of Robert's uterus. Operative hysteroscopy under general anesthesia (laryngeal mask) was subsequently performed using a 15 Fr bipolar mini-resectoscope. Hysteroscopic unification of the unicornuate cavity and blind horn was achieved by progressive latero-lateral septal incision with a Collins loop under transabdominal ultrasound guidance, establishing communication between the cavities. The septum was incised up to the interostial plane, and the right uterine wall was further incised to enlarge the cavity. A 90° angled loop was then used to remove redundant tissue, restoring normal uterine architecture. Postoperative 3D ultrasound confirmed successful unification. No peri- and/or post-operative complications occurred. The patient was discharged three hours after surgery. Outpatient hysteroscopic follow-up at 35 days showed a normally shaped uterine cavity.

Conclusion: Robert's uterus can be effectively and safely managed through a minimally invasive hysteroscopic approach using a 15 Fr bipolar mini-resectoscope under transabdominal ultrasonographic guidance. This technique provides a safe, efficient alternative to more invasive surgical options. Further larger studies are required to validate the surgical technique and assess long-term reproductive outcomes.