Journal of minimally invasive gynecology最新文献

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.

Study objective: To develop and validate a machine-learning (ML) model using preoperative clinical and imaging variables including ultrasound and diagnostic hysteroscopy findings to predict incomplete hysteroscopic myomectomy among women with submucosal leiomyomas.

Design: Retrospective cohort study.

Setting: Tertiary referral center for minimally invasive gynecologic surgery with expertise in operative hysteroscopy (Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel).

Patients: A total of 345 procedures from 328 women who underwent hysteroscopic myomectomy for submucosal leiomyomas between January 2012 and December 2024 were included.

Measurements and main results: Incomplete resection was defined as any documented residual submucosal myoma at the end of surgery. The overall rate of incomplete myomectomy was 16.2% (56/345). For model development, complete resection was coded as the positive class and individual risk of incomplete resection was obtained as 1-P(complete resection). A CatBoost binary classifier was trained using stratified 5-fold patient-level cross-validation. The model achieved moderate discrimination and high average precision for this imbalanced prediction task (AUROC = 0.72, average precision = 0.93) and outperformed logistic regression trained on identical inputs, with high PPV and sensitivity but only moderate specificity at the prespecified 0.50 probability threshold. FIGO type (2), larger myoma diameter, and multiplicity were the strongest predictors of incomplete resection. SHAP analysis confirmed consistent feature effects across folds, highlighting myoma morphology as the main driver of model predictions.

Conclusion: A ML model integrating preoperative clinical and imaging data from ultrasound and diagnostic hysteroscopy predicted incomplete hysteroscopic myomectomy with moderate discrimination and modestly outperform conventional regression. This approach may help guide preoperative counseling and surgical planning by providing clinically useful risk estimates for incomplete hysteroscopic myomectomy.

Objective: To evaluate variation in ovarian preservation and excision of extra-ovarian endometriosis during endometrioma surgery across gynecologic subspecialties.

Design: Retrospective cohort study.

Setting: One tertiary academic medical center and four regional hospitals within a single health system.

Participants: Individuals aged 18-45 years who underwent surgery for pathology-confirmed ovarian endometrioma between 2012 and 2024. Exclusion criteria included hereditary cancer syndromes, prior malignancy, malignancy on final pathology, non-gynecologic surgeons, and incomplete documentation. The final cohort comprised 351 patients.

Interventions: Surgical management was assessed across four gynecologic subspecialties: general obstetrics and gynecology (OBGYN), minimally invasive gynecologic surgery (MIGS), reproductive endocrinology and infertility (REI), and gynecologic oncology (GYNONC). The primary outcome was ovarian-sparing surgery, defined as cystectomy without oophorectomy. The secondary outcome was excision of extra-ovarian endometriosis among patients with advanced-stage disease (rASRM stage III or IV). Multivariable logistic regression was used to adjust for clinical and surgical factors.

Results: Ovarian-sparing surgery was performed in 66% of cases and varied by surgeon subspecialty. Compared with OB/GYN surgeons, MIGS and REI surgeons had higher odds of ovarian-sparing surgery (adjusted odds ratio [aOR] 8.46, 95% confidence interval [CI] 3.07-23.29 and aOR 8.44, 95% CI 2.71-26.27, respectively; both p < 0.001). Among patients with advanced-stage disease, excision of extra-ovarian endometriosis also differed by subspecialty, with MIGS and REI surgeons demonstrating higher odds of extra-ovarian excision compared with OB/GYN surgeons (aOR 23.18, 95% CI 8.18-65.72 and aOR 13.09, 95% CI 4.44-38.63, respectively; both p < 0.001).

Conclusion: Surgical management of ovarian endometriomas varied across gynecologic subspecialties. Compared with OB/GYN and GYNONC surgeons, MIGS and REI surgeons were more likely to perform ovarian-sparing surgery and excise extra-ovarian endometriosis.

Title: Robotic Sentinel Lymph Node Biopsy in Apparent Early-Stage Ovarian Cancer OBJECTIVE: To demonstrate the feasibility and technical aspects of robotic sentinel lymph node (SLN) biopsy using indocyanine green (ICG) in a patient with apparent early-stage ovarian cancer, highlighting critical steps to optimize lymphatic mapping and node detection.

Setting: The procedure was performed at Hospital La Fe, a tertiary referral center with expertise in minimally invasive gynecologic oncology and robotic-assisted surgery.

Participants: A 52-year-old woman diagnosed with grade 3 endometrioid ovarian carcinoma after a previous adnexectomy, clinically staged as FIGO IA, was referred for surgical restaging, including sentinel lymph node mapping.

Interventions: A single tracer, indocyanine green (ICG), was injected into the stumps of the infundibulo-pelvic and utero-ovarian ligaments to map the para-aortic and pelvic lymphatic fields, respectively ^1,2,3. Low-volume injections (0.2-0.5 mL at 1.25 mg/mL) were used at each point, subperitoneally, at a depth of less than 0.5 cm^1,3. Near-infrared fluorescence imaging, integrated into the Da Vinci robotic system, enabled intraoperative lymphatic mapping and real-time identification of SLNs. The node was detected 30 minutes after the injection in both areas. SLNs were successfully identified in both regions, including a pelvic node on the external iliac vessels and two para-aortic nodes in the para-caval area. Key technical considerations to minimize tracer extravasation and ensure accurate node detection are highlighted, including careful needle manipulation, aspiration to avoid vascular puncture, and sealing of the injection site. The planned standard staging surgery was then completed: hysterectomy, contralateral adnexectomy, omentectomy, peritoneal citology and pelvic and para-aortic lymphadenectomy. Lymphadenectomy was performed from the obturator nerves and vessels (depth limit) until the renal vein (upper limit). SLN was confirmed at definitive pathology analysis performing ultrastaging protocol³, without identifying metastases in this case.

Conclusion: This case supports the feasibility of robotic SLN biopsy in ovarian cancer using ICG. This approach may offer a less invasive alternative to systematic lymphadenectomy in these patients, if further studies are able to demonstrate SLN diagnostic accuracy compared with standard procedure.

Objective: To evaluate the reproducibility, mid-term efficacy, and safety of transvaginal ultrasound-guided radiofrequency (RF) ablation of uterine fibroids among multiple centers and operators.

Design: Prospective multicenter observational study.

Setting: Eleven public and private hospitals in Spain.

Patients: A total of 393 women with symptomatic uterine fibroids treated between May 2021 and June 2024.

Interventions: All procedures were performed using a standardized transvaginal RF ablation protocol (VIVA RF System, STARmed Co.) after formal training of participating gynecologists.

Measurements and main results: Clinical and ultrasonographic data were prospectively collected at baseline, 12, and 24 months. The mean baseline fibroid volume was 35.2 ± 45.0 cm³, decreasing to 12.2 ± 24.2 cm³ at 12 months (65.3% reduction, p<0.05). Symptom Severity Score (SSS) improved from 25.6 ± 7.7 to 15.5 ± 6.0 at 12 months and 14.7 ± 5.6 at 24 months (p<0.05). The overall complication rate was 5%, with 90% classified as Clavien-Dindo I. Smaller initial fibroid volume (β = -0.18; 95% CI, -0.35 to -0.02; p = 0.031) and patient age ≥ 41 years (β = +14.7; 95% CI, 0.40-29.0; p = 0.044) were independent predictors of greater volume reduction. Inter-center analysis revealed significant differences only in one hospital, confirming high reproducibility across operators.

Conclusion: Transvaginal RF ablation is a safe, effective, and reproducible uterus-preserving treatment for symptomatic fibroids. Standardized training and adherence to unified procedural protocols may further optimize outcomes and minimize variability among centers.