Journal of minimally invasive gynecology最新文献

Study objective: To compare ablative energy technologies and evaluate their ability to destroy in vivo endometriosis tissue in humans.

Design: Prospective, randomized, triple-arm, single-blind, clinical trial.

Setting: Good Samaritan Hospital, Cincinnati, Ohio.

Participants: Women undergoing excision of lesions for pelvic pain symptoms or endometriosis by a high-volume minimally invasive gynecologic surgeon.

Interventions: During the already planned excision of lesions, just prior to excision, identified lesions were uniquely numbered and randomized to ablative treatment with either 1) electrical diathermy, 2) Argon beam coagulation, or 3) CO₂ laser. The lesions were ablated with the assigned technologies. Excision of the ablated lesions was then performed for pathologic evaluation.

Measurements and main results: The primary outcome was the frequency of positive histology for endometriosis within the ablated surgical specimens. Sample size was calculated in advance to be 140 samples, which would provide power of 0.8 and significance of 0.0167. A total of 153 samples of ablated lesions were excised and collected from a total of 34 patients, with 51 samples in each of the three surgical technology arms. Overall, 20 (13%) of the ablated lesions still contained endometriosis identified on pathology after subsequent excision. Stratified by treatment arm, the numbers of specimens that remained endometriosis-positive after ablative treatment were 10 (20%) for electrical diathermy, 4 (8%) for Argon beam coagulation, and 6 (12%) for CO₂ Laser (p=0.20).

Conclusion: No difference was detected in comparing the histologic effectiveness of Diathermy, CO₂ laser, and Argon, when used to destroy endometriosis. Excision is able to remove disease left behind after ablation.

Clinical trial registration: NCT06414083. Registered Date May 09, 2024.

Firstly, this meta-analysis[1] included a total of eight studies, seven of which used the rASRM classification, while only one applied the ENZIAN classification; the latter was not included in the pooled analysis due to insufficient data. Based on these findings, the authors concluded that pain intensity was not significantly associated with rASRM stage. However, we believe that this conclusion is, at least in part, constrained by the inherent structural limitations of the rASRM classification itself. The rASRM classification[2,3] was originally developed to evaluate fertility outcomes, with its scoring primarily emphasizing the extent and severity of peritoneal and ovarian lesions as well as adhesions, rather than adequately capturing deep infiltrating endometriosis involving neural, rectal, or bladder structures. These anatomical sites, however, are closely associated with key symptoms such as chronic pelvic pain, dyspareunia, dyschezia, and dysuria. Consequently, in a meta-analysis[1] focusing on pain type and intensity as primary outcomes, reliance solely on rASRM staging may lead to a systematic underestimation of the true association between lesion anatomy and symptom burden. Secondly, the inclusion criteria of this meta-analysis[1] required that all participants have surgically and histologically confirmed endometriosis. However, in clinical practice, not all patients with symptomatic endometriosis undergo surgical treatment. The decision to proceed with surgery is often influenced by multiple factors, including symptom severity, response to medical therapy, coexisting infertility, or suspicion of advanced disease. Consequently, the population represented in this meta-analysis may be skewed toward patients with more severe symptoms, more complex disease, or disease refractory to medical management.

Objective: To explore the role of intraoperative transvaginal ultrasound in surgical planning for bowel deep endometriosis involving the rectum, rectosigmoid junction, and inferior sigmoid colon [1].

Setting: Pilot study in the form of a descriptive, step-by-step demonstration with narrated video content illustrating intraoperative transvaginal ultrasound to assess the extent of rectosigmoid deep endometriosis in a university hospital setting.

Participants: Five women with suspicion of rectosigmoid deep endometriosis undergoing laparoscopic surgery.

Interventions: Patients underwent oral bowel preparation the day before surgery. Intraoperative transvaginal ultrasound was performed after pelvic dissection and rectal mobilization to assess the extent and depth of deep endometriosis involving the rectum, rectosigmoid junction, and inferior sigmoid colon, and to guide the surgical approach-shaving, disc excision, or colorectal resection. All scans were performed by a single gynecologist experienced in endometriosis surgery and ultrasound imaging.

Conclusion: Intraoperative transvaginal ultrasound was feasible for evaluating bowel deep endometriosis involving the rectum, rectosigmoid junction, and inferior sigmoid colon across different surgical scenarios. The technique provided reliable information on lesion localization, size, and depth. It complemented visual and tactile intraoperative assessments, aiding in surgical decision-making. Compared to preoperative imaging, intraoperative ultrasound provides the benefit of being performed after pelvic organ mobilization, enabling a potentially more precise assessment of the lesions. This technique may help in selecting the most appropriate and least invasive bowel surgical approach, reduce the risk of residual disease, and aid in the standardization of rectosigmoid endometriosis surgery [2-5].

Objective: The objective of this video is to describe a case of disseminated peritoneal leiomyomatosis (DPL) mimicking deeply infiltrating endometriosis and discuss the preoperative workup, intraoperative approach, and postoperative considerations. We also illustrate key surgical techniques to optimize safe and complete resection, including use of indocyanine green (ICG) for ureteral identification and strategic use of retractors for improved visualization and mobilization of lesions.

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

Participants: A 48-year-old patient with a remote history of laparoscopic hysterectomy for uterine fibroids that required morcellation, although it was unknown if this was performed in a contained fashion. She presented with chronic cyclical pelvic pain, urinary urgency, and tenesmus. She was started on progestin therapy for presumed endometriosis, with incomplete symptom relief.

Intervention: Pelvic MRI revealed nodular thickening of bilateral round ligament remnants, a spiculated fibrotic lesion with hemorrhagic foci involving the right ovary and terminal ileum, and a lobulated mass abutting the bladder and vaginal cuff. Laparoscopic surgical excision was planned during which leiomyomatous lesions noted at the umbilicus, vaginal cuff, bladder, and round ligament remnants. Cystoscopy-guided ureteral instillation of ICG was used to aid ureteral identification, and rectal and vaginal retractors were used to delineate anatomy.

Conclusion: DPL is an uncommon and often misdiagnosed condition that may mimic deep endometriosis. Recognition of its iatrogenic association highlights the importance of contained morcellation during gynecologic surgery. Preoperative imaging and intraoperative identification of critical structures, such as the ureters, bladder and rectal borders, enable safe, complete excision with low risk of recurrence.

Study objective: To compare the efficacy of individualized poly-DL-lactic acid (PDLLA)- copper stents versus intrauterine balloons (Cook balloon) in improving reproductive outcomes and preventing adhesion recurrence following hysteroscopic adhesiolysis (HA).

Design: Retrospective cohort study.

Setting: A tertiary university hospital.

Patients: 399 consecutive women diagnosed with moderate-to-severe intrauterine adhesions (IUAs) who underwent HA with cold scissors and received an individualized PDLLA-copper stent (Stent group, n=139) or a COOK balloon (COOK group, n=260) from January 2019 to December 2022.

Interventions: All cases were reviewed. Inverse probability of treatment weighting (IPTW) was applied to mitigate selection bias and ensure comparability between the groups.

Main results: Compared with the Cook Group, the Stent Group demonstrated a significantly higher clinical pregnancy rate (62.4% vs. 48.6%; Hazard Ratio [HR] 1.59, 95% confidence interval [CI] 1.16-2.19), a lower miscarriage rate (14.3% vs. 28.0%; Relative Risk [RR] 0.51, 95% CI 0.27-0.98), and a reduced adhesion recurrence rate (14.1% vs. 32.6%; RR 0.43, 95% CI 0.23-0.82). The median time to pregnancy was also significantly shorter in the Stent Group (11 months versus 18 months; P = .003). However, no statistically significant difference in clinical pregnancy rate was observed between the two groups among patients with severe IUAs. Live birth rates did not differ significantly across the analyses.

Conclusion: The individualized PDLLA‑copper stent represents a promising alternative approach for improving reproductive outcomes and reducing adhesion recurrence particularly in patients with moderate IUAs after HA with cold scissors.

Study objective: To evaluate the diagnostic performance of pretreatment serum CA125 level, computerized tomographic (CT) scan, and their combination in detecting extra-uterine disease, including pelvic lymph node metastasis, among patients with apparently early-stage endometrial cancer.

Design: Retrospective cross-sectional study.

Setting: Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Patients: A total of 399 patients with apparently early-stage endometrial cancer who underwent surgical staging with lymphadenectomy between January 2016 and July 2024 and had both preoperative CA125 levels and CT scans available for review.

Interventions: Preoperative serum CA125 levels were analyzed, and CT scans were independently reviewed by radiologists blinded to clinical and laboratory data. Diagnostic performance was assessed against final pathological findings.

Measurements and main results: The performance of CA125, CT scan, and their combination was evaluated for predicting extra-uterine and pelvic nodal disease. A CA125 cutoff >35 U/mL combined with CT scan demonstrated acceptable diagnostic ability, with an AUC-ROC of 0.792 (95% CI, 0.737-0.848) for detecting extra-uterine metastasis and 0.834 (95% CI, 0.776-0.892) for pelvic lymph node metastasis. When an optimized CA125 cutoff of ≥28.35 U/mL was combined with a CT scan, diagnostic performance for pelvic nodal involvement was markedly enhanced, achieving an AUC-ROC of 0.909 (95% CI, 0.888-0.929), reflecting excellent accuracy. These findings suggest that using both biomarkers and imaging synergistically provides superior predictive value compared with either modality alone.

Conclusion: Pretreatment serum CA125 combined with CT scan yields high diagnostic accuracy for detecting extra-uterine disease and pelvic lymph node metastasis in apparently early-stage endometrial cancer. This approach may guide preoperative counseling, optimize surgical planning, and support the adoption of minimally invasive strategies in suitable patients.

Objective: To describe the successful minimally invasive management of a giant paratubal cyst using total vaginal Natural Orifice Transluminal Endoscopic Surgery (tvNOTES).

Setting: Tertiary referral center specializing in minimally invasive gynecologic surgery.

Participants: A 34-year-old multiparous woman presented with abdominal discomfort and a visible lower abdominal bulge. Magnetic resonance imaging revealed a giant unilocular cyst (28 × 25 × 12 cm) with pure fluid content occupying the entire abdominopelvic cavity. Hypertrophy of the right utero-ovarian ligament suggested a right adnexal origin. Tumor markers were within normal limits.

Interventions: A tvNOTES approach was selected as it combines endoscopic precision with no visible scar, providing clear visualisation and improved surgeon ergonomics. Contrary to conventional vNOTES, in which the inner ring of the Alexis O Retractor (Applied Medical, Rancho Santa Margarita, CA) is positioned within the peritoneal cavity, a 7-cm Alexis O Retractor was placed circumferentially within the vagina around the cervix. The GelSEAL Cap (Applied Medical, Rancho Santa Margarita, CA) with four trocars was then secured to the anterior perineum. Pneumovagina was maintained at 12 mmHg using a thoracic drainage bottle, with active smoke evacuation. A 3 cm posterior colpotomy was performed under endoscopic guidance, revealing a giant right paratubal cyst. The cyst was incised at its most dependent point and drained of 5 liters of clear fluid. A right salpingectomy was performed due to fallopian tube elongation, preserving the ovarian blood supply. The procedure lasted 40 minutes without complications. The patient was discharged 6 hours postoperatively with minimal pain.

Conclusion: TvNOTES allows all surgical steps under endoscopic visualization, with the potential for rapid recovery, minimal postoperative pain, and ovarian preservation, even in cases involving very large paratubal masses. TvNOTES may represent a feasible approach for the minimally invasive management of giant adnexal cysts.

Objective: Reprocessing of single-use surgical devices (SUDs) can provide an impactful reduction in surgical waste and greenhouse gas emissions, but there is minimal data on surgeon preference and surgical performance of these reprocessed SUDs compared to new devices. This study aims to compare gynecologic surgeon assessment of the reprocessed versus new laparoscopic LigaSure bipolar vessel sealing devices.

Design: This was a double-blind, randomized, 2 × 2 cross-over surgical simulation study, in which participants completed a series of surgical tasks with both a new and reprocessed laparoscopic LigaSure. The primary outcome was surgeon assessment of the devices and secondary outcomes included surgeon willingness to use reprocessed SUDs in clinical practice.

Setting: 2024 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in New Orleans, LA PARTICIPANTS: A total of 20 gynecologic surgeons from across the United States with varying levels of experience completed the study.

Interventions: Participants used a new and reprocessed laparoscopic LigaSure device in sequence, with the order randomly assigned. Participants completed a series of instructed surgical tasks using a tissue model, and subsequently assessed each device in regard to tissue handling, tissue dissection, seal completion, tissue cutting, and ergonomics using a continuous numeric scale (0-10). Participants then answered questions about overall device assessment.

Results: Wilcoxon signed rank and Generalized Linear Mixed Models were used for statistical analysis. There was no significant difference in any aspects of the assessed performance of the new versus reprocessed device. This persisted with adjustment for surgeon sex and the type of LigaSure used in the simulation model (blunt or Maryland tip). Most participants (70%) accurately guessed which device was reprocessed, but only 30% preferred the new device to the reprocessed. 90% of the participants were willing/interested in using reprocessed laparoscopic LigaSure devices in their surgical practice.

Conclusion: The findings of this study further support the broader adoption of surgical SUD reprocessing, reinforcing ongoing efforts to mitigate healthcare's contribution to climate change.