Journal of minimally invasive gynecology最新文献

Objective: To demonstrate a step-by-step technique of intraoperative intraureteric indocyanine green (ICG) administration under cystoscopic guidance to localize intraoperative ureters under near-infrared fluorescence imaging during laparoscopic deep endometriosis surgery. The standardization and description of the surgery in 10 steps are the main objective of this video (Video 1).

Setting: A university tertiary care hospital DESIGN: Step-by-step video demonstration of the technique PARTICIPANT: Patient who diagnosed with deep endometriosis underwent laparoscopic surgery treatment. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case.

Intervention: Ten main steps of cystoscopy with of intraureteral ICG administration to allow real time visualization of intraoperative ureters during adhesiolysis and endometriosis resection were described in detail: step 1 preparing ICG; step 2 preparing ureteric catheter; step 3 preparing instruments for cystoscopy; step 4 cystoscopy; step 5 identify the ureteric orifices; step 6 insertion ureteric catheter through ureteric orifices; step 7 injection of ICG; step 8 laparoscopic surgery; step 9 intraoperative visualization of ureters; and step 10 deep endometriosis surgery CONCLUSION: The use of cystoscopy-guided intraureteric ICG dye instillation and intraoperative ureteric near-infrared fluorescence imaging is a safe and effective tool for visualization of the ureteric position precisely and in real time, making the procedure faster, easier and reduce the intraoperative ureteric complication during laparoscopic deep endometriosis surgery.

Objective: To demonstrate a minimally invasive surgical approach for managing a retained intrauterine device (IUD) in a patient with severe cervical stenosis and a cesarean scar defect.

Setting: Tertiary care center with expertise in complex gynecologic surgery.

Participants: A 33-year-old G1P1001 with a history of cesarean delivery. She had a prior LEEP and IUD insertion, followed by cold-knife conization where IUD strings were transected. She presented with pelvic pain, irregular bleeding and cervical stenosis. She underwent multiple failed IUD removal attempts complicated by uterine and rectovaginal septum perforations. Imaging revealed an isthmocele with minimal residual myometrium and cervical shortening.

Intervention: Patient underwent laparoscopic transuterine IUD removal, transuterine cervical dilation with intrauterine catheter placement to maintain cervical patency, isthmocele repair, and transabdominal cerclage. Transabdominal approach was selected over transvaginal cerclage or expectant management due to severe cervical distortion from prior excisional procedures and cervical shortening.

Objective: To evaluate whether adding metronidazole to cefazolin for hysterectomy is more effective in prevention of surgical site infection than the existing recommendation of cefazolin alone.

Data sources: MEDLINE, ClinicalTrials.gov, EMBASE, Cochrane Library, and Web of Science were searched until October 16, 2024. The following words made up the search strategy: hysterectomy, cefazolin, metronidazole, and surgical site infection, and their variants.

Methods of study selection: Our search identified 987 studies, which were uploaded to Covidence for review management; 302 duplicates were automatically removed. A team of two reviewers screened 685 studies, and a third reviewer resolved conflicts. Studies were included if they 1) consisted of peer-reviewed research published between 1980 and 2024, 2) assessed patients undergoing hysterectomy by any route, 3) compared cefazolin to cefazolin and metronidazole, and 4) reported primary outcome of surgical site infection within 30 days of procedure.

Tabulation, integration, and results: Five studies with a total of 5,838 participants met eligibility criteria; two were randomized controlled trials (RCTs) and three were observational (retrospective cohort studies). The two RCTs each used vaginal metronidazole and the three observational studies each used intravenous (IV) metronidazole. The RCTs each found qualitatively lower risk of SSI with vaginal metronidazole compared to cefazolin alone (ORs 0.28 and 0.43). Observational studies consistently found similar ORs for lower risk of surgical site infection (SSI) with IV metronidazole compared to cefazolin alone (OR range 0.40-0.63). These large effect sizes were statistically significant in only the two largest studies, reflecting limited statistical power of several individual studies due to low absolute frequencies of infections.

Conclusion: Systematic review of the literature demonstrates evidence that the use of metronidazole in addition to cefazolin reduces the risk of surgical site infection after hysterectomy by any route and for any indication. Intravenous use of metronidazole in particular may be the preferred route of administration by both the patient and surgeon.

This report presents a patient with deeply infiltrating bladder endometriosis who underwent laparoscopic excision with partial cystectomy, revealing focal atypical endometrial hyperplasia within the bladder nodule on histopathology. The case highlights the importance of surgical planning, thorough surgical excision and histologic assessment of complex endometriosis cases, as well as the need for individualized management and surveillance strategies when atypia is identified in extrauterine endometriotic disease.

Objective: Fluorescence imaging using indocyanine green (ICG) has recently gained widespread use in gynecologic surgery and is considered a useful method for facilitation of ureteric identification and dissection during deep endometriosis (DE) surgery [1-3]. However, we encountered a case of DE in which ureteral visualization using intraureteral ICG was inadequate. This video presents clinical details and discusses possible reasons and implications.

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

Participants: A 42-year-old woman presented with dysmenorrhea and chronic pelvic pain. She had a history of surgery for DE (ovarian cystectomy and uterosacral ligament resection). MRI showed uterine leiomyomas, adenomyosis, bilateral ovarian endometrioma, left hematosalpinx, and DE involving the surface of the rectum and uterosacral ligament.

Interventions: Robot-assisted nerve-sparing hysterectomy with bilateral salpingo-oophorectomy and complete DE resection was planned using the da Vinci SP. Retrograde intraureteral ICG instillation was performed cystoscopically using ureteral catheters (2.5 mg/mL, 5 mL per side). Due to severe pelvic adhesion and fibrosis, the course of the pelvic ureters could not be identified with ICG fluorescence alone. The non-visualized segment became visible only after careful dissection of fibrotic tissue, and some portions remained non-fluorescent even after complete exposure of the ureter.

Conclusion: Even minimal periureteral fibrosis, as thin as 1-2 mm, can significantly attenuate fluorescence transmission depending on its density [4, 5]. Although intraureteral ICG is a valuable adjunct for ureteral identification during DE surgery, surgeons should be aware of its optical limitations and rely on meticulous anatomical dissection, which remains the cornerstone of safe pelvic surgery.

Objective: To compare the oncologic outcomes of sentinel lymph node mapping (SLNM) and systemic lymphadenectomy (LND) in patients with high-risk endometrial cancer (EC) using a meta-analysis.

Data sources: PubMed, Embase, and the Cochrane Library were systematically searched from inception to November 2024 using terms related to "sentinel lymph node," "lymphadenectomy," and "endometrial cancer," with no language or publication date restrictions.

Methods of study selection: Retrospective studies comparing SLNM and LND in high-risk or high-intermediate-risk EC were included. Thirteen studies met eligibility criteria, comprising 1,405 patients in the SLNM group and 7,606 in the LND group.

Tabulation, integration, and results: Overall, 13 retrospective studies were included (SLNM, 1405 patients; LND, 7606 patients). No significant differences in recurrence (HR = 0.89; 95% CI: 0.74-1.07; I² = 0; P < 1.00) and mortality (HR = 0.72; 95% CI: 0.56-1.01; I² = 63.3; P = 0.001) were observed between the two groups. Subgroup analysis according to histology with mortality data showed no increase in mortality with carcinosarcoma, serous carcinoma, and clear cell carcinoma (HR = 0.51; 95% CI: 0.38-0.67; I² = 0.0; P = 0.001). Further subgroup analysis according to stage, histology, and risk groups supported the overall findings, showing no significant differences between SLNM and LND.

Conclusion: SLNM alone for high-risk EC did not increase recurrence or mortality when compared to LND. Although SLNM offers several advantages, such as reduced complications and improved quality of life, further prospective studies are needed to confirm these findings and refine SLNM guidelines in high-risk EC.

Study objective: To compare the safety and efficacy of laparoscopic versus transvaginal ethanol sclerotherapy in patients with ovarian endometriomas (OEMs).

Design: Preliminary retrospective cohort study SETTING: Reproductive Medicine Research Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, China & Fertility Center, Shenzhen Hengsheng Hospital, Shenzhen, Guangdong, China.

Intervention: laparoscopic ethanol sclerotherapy or transvaginal ethanol sclerotherapy MEASUREMENTS AND MAIN RESULTS: From June 2019 to June 2024, 124 patients with OEMs were divided into two groups: transvaginal (n=62) and laparoscopic (n=62) ethanol sclerotherapy. After 1:1 propensity score matching, 42 patients remained in each group with balanced baseline characteristics. All returned for controlled ovarian hyperstimulation (COH) 2 months postoperatively. No severe complications occurred. The laparoscopic group showed a significantly less decline in AMH (-0.18 vs. -0.27 ng/mL, p=0.042). The number of oocytes retrieved was similar (9.5 vs. 9.5, p=0.890). Fertilization rates (75.4% vs. 64.7%, p<0.001) and high-quality D3 embryo formation rates (60.6% vs. 45.4%, p<0.001) were significantly higher in the laparoscopic group, with D3 embryo formation rates marginally higher (80.4% vs. 73.9%, p=0.057). Blastocyst development and rates of no embryo availability did not differ. After adjustment, biochemical pregnancy rate (77.5% vs. 64.3%, OR=1.304, 95% CI: 0.434-3.936, p=0.634), clinical pregnancy rate (57.5% vs. 59.5%, OR=0.885, 95% CI: 0.321-2.437, p=0.813), and live birth rate (52.5% vs. 57.1%, OR=0.954, 95% CI: 0.348-2.615, p=0.927) showed no significant difference.

Conclusion: Both transvaginal and laparoscopic ethanol sclerotherapy were safe options for treating ovarian endometriomas. But laparoscopic surgery proved better preserve ovarian reserve and improve embryo development.

Trial registration: Not applicable.

Objective: To show the safety of en bloc hysterectomy with segmental bowel resection utilizing the NOSE-technique in the management of ovarian cancer and deep infiltrating endometriosis (DIE).

Design: Demonstration of the technique with narrated video.

Settings: Endometriosis, particularly endometriomas, increases the risk of epithelial ovarian cancer and complicates surgical management. En bloc hysterectomy with NOSE-assisted anastomosis offers a less invasive, effective alternative, improving outcomes and recovery.

Participant: A 39-year-old patient with DIE and an adnexal mass (ORADS-4), diagnosed with endometrioid adenocarcinoma involving both ovaries (FIGO-Stage-IIB).

Interventions: Laparoscopic en bloc hysterectomy with bowel resection and cytoreduction was performed, with intestinal anastomosis via the NOSE-technique.

Conclusions: En bloc hysterectomy with NOSE anastomosis reduces morbidity, enhances visualization, recovery, and achieves effective cytoreduction, offering a less invasive option for ovarian cancer with DIE.