Journal of minimally invasive gynecology最新文献

Objective: We aimed to evaluate the non-inferiority of ultrasound-guided transvaginal puncture compared with laparoscopic drainage in the treatment of tubo-ovarian abscesses (TOA).

Design: We conducted a prospective, randomised, two-arm, parallel, non-inferiority, uni-centric, therapeutic trial comparing two surgical techniques for the management of TOA: echo-guided transvaginal puncture and laparoscopic drainage.

Subjects: were patients aged 18 to 43 years with a tubo-ovarian abscess visible on ultrasound or CT scan, larger than 2 centimeters, without signs of complications. The per-protocol analysis, as recommended for non-inferiority trials, included 38 patients.

Intervention: Ultrasound-guided transvaginal puncture and with laparoscopic drainage in the treatment of tubo-ovarian abscesses MAIN OUTCOMES MEASURES: The Main outcome was the rate of cure measured a composite score: clinical improvement (pain and temperature) and biological improvement (regression of biological inflammatory syndrome). The secondary endpoints take into account various aspects of the early and late post-operative period.

Results: Transvaginal puncture under ultrasound is no less effective than laparoscopy in the treatment of OAT associated with IV antibiotic therapy. It also showed that transvaginal puncture had the advantage of reducing the operating time and morphine consumption during hospitalisation. No difference was observed between the two techniques on the 1-month follow-up ultrasound.

Conclusion: The best treatment for a tubo-ovarian abscess should be that which is the safest, most effective, least invasive, least expensive and least detrimental to female fertility. Transvaginal puncture seems to meet these criteria; thanks to the DATO study, we were able to show that this procedure was no less effective than laparoscopy in terms of early cure.

Study object: To investigate what factors affect reproductive outcomes after hysteroscopic septum incision.

Design: A single-center retrospective cohort study.

Setting: A tertiary university hospital.

Patients: 1426 women with uterine septum who underwent hysteroscopic septum incision.

Interventions: Hysteroscopic septum incision.

Measurements and main results: Of 1426 women undergoing hysteroscopic septum incision, 1238 cases attempted to conceive after surgery. The primary outcome measures were the outcome of the first pregnancy following septum surgery and factors affecting these outcomes. The secondary outcome measures included (1) pregnancy rate and (2) cumulative live birth rate (LBR) by 12, 24,36 months after surgery. Overall, 1121 of 1238 women (90.5%) conceived, resulting in a LBR of 932/1111 (83.9%). Women with prior mid-trimester loss showed a significantly higher risk of mid-trimester miscarriage postoperatively compared to other groups (odds ratio[OR] = 4.08, 95% confidence interval [95% CI]: 1.86-8.97). Women with multiple indications demonstrated significantly lower term birth rate versus those with a single indication (OR=0.54, 95%CI [0.39, 0.75]). No significant outcome differences were observed between incomplete and complete septa. In the subgroup with postoperative three-dimensional (3D) ultrasound fundal assessment, women with fundal indentation ≤ 5 mm showed a significantly higher pregnancy rate than those with > 5mm (95.7% vs. 76.0%; p = 0.035), though with comparable live birth rates (90.9% vs. 89.5%; p > 0.05).

Conclusion: Women with uterine septa represent a heterogeneous population. Clinical outcomes depend on both preoperative reproductive history and postoperative fundal indentation depth, but are unaffected by initial septum type (incomplete vs. complete). Careful postoperative assessment and individualized counseling may help optimize patient management.

Objective: To evaluate the predictive value of native T1 and extracellular volume fraction (ECV) based on T1 mapping imaging for the postoperative efficacy of microwave ablation (MWA) of uterine fibroids.

Design: prospective study SETTING: The First Hospital of Hebei Medical University PATIENTS: 59 patients with pathologically confirmed uterine fibroids who underwent microwave ablation (MWA) between January 2023 and January 2024.

Methods: All patients underwent preoperative conventional MRI, T1mapping and DWI imaging of the uterus. Conventional MRI features, native T1, ECV and apparent diffusion coefficient (ADC) values were compared between the two groups. Prognostic risk factors were identified using univariate and multivariate logistic regression. ROC curves for postoperative outcomes were plotted based on risk factors.

Results: Of the 134 fibroids (59 patients), 90 and 44 were stratified into the effective and ineffective prognosis groups, respectively. Significant intergroup differences were found in tumor homogeneity, T2 hyperintensity, border clarity, volume, pre-/post-contrast T1 values, and ECV. For predicting efficacy, AUCs for pre-contrast T1, post-contrast T1, and ECV were 0.867, 0.850, and 0.585, respectively. Combined models yielded AUCs of 0.920 (T1 mapping + ECV), 0.869 (conventional imaging alone), and 0.953 (conventional + T1 mapping) (all P < 0.05).

Conclusion: The native T1 and ECV values had good predictive value for predicting the efficacy of MWA treatment for uterine fibroids, with the combination of conventional imaging features+T1 mapping parameters having the greatest predictive value.

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.