Journal of minimally invasive gynecology最新文献

Study objective: Although mean/static compliance of bladder filling can be readily assayed via cystometry, a protocol measuring compliance dynamics at a specific stage of bladder filling has not been established in human patients. For patients with pelvic organ prolapse (POP), the objective benefits of robotic-assisted sacrocolpopexy (RSCP) surgical intervention for restoring bladder functions, primarily urine storage, have yet to be established. Also, bladder compliance is a viscoelastic parameter that crucially defines the storage function. Therefore, we aimed to investigate the impact of RSCP on bladder compliance of POP patients using a pressure-volume analysis (PVA), which graphically illustrates bladder compliance.

Design: A retrospective pre and postoperative study.

Setting: Multiple hospitals in Taiwan.

Patients: Twenty seven female POP patients (stage ≥ II).

Intervention: RSCP for POP repair.

Measurements and main results: We retrospectively reviewed the pre- and postoperative PVAs for women with POP who underwent RSCP. The mean compliance of the entire (Cm), the early half (C1/2), and the late half (C2/2) of bladder filling were analyzed as primary outcomes. Changes in intravesical volume (ΔVive) and detrusor pressure (ΔPdet) of bladder filling, ΔPdet in the early (ΔPdet1/2) and late (ΔPdet2/2) filling, and postvoiding residual volume (Vres) were analyzed as secondary outcomes. Compared with the preoperative control, RSCP increased Cm (p = .010, N = 27) and C2/2 (p <.001, N = 27) but negligibly affected C1/2 (p = .457, N = 27). Mechanistically, RSCP decreased ΔPdet (p = .0001, N = 27) without significantly affecting ΔVive (p = .863, N = 27). Furthermore, RSCP decreased the ΔPdet2/2 (p <.001, N = 27) but not ΔPdet1/2 (p = .295, N = 27).

Conclusions: This is the first report on applying PVA in assaying dynamics of bladder compliance in patients with POP. Our results suggest that RSCP improved bladder storage in women with POP since it increased bladder compliance, particularly in the late filling, possibly by restoring the anatomical location and geometric conformation for bladder expansion.

Study objective: To evaluate the impact of virtual versus in-person preoperative evaluation on perioperative complication rates in a minimally invasive gynecologic surgery (MIGS) practice.

Design: Retrospective cohort study.

Setting: Quaternary care academic hospital in the United States.

Participants: Patients who underwent surgery with a MIGS surgeon between January 2016 and May 2023.

Interventions: Patients underwent either in-person or virtual preoperative visits (defined as the initial consultation and any subsequent follow-up or preoperative counseling visits). Those who had both an in-person and virtual preoperative visit were excluded. Complication rates among the virtual and in-person cohorts were compared, and logistic regression was performed to adjust for potential confounders.

Results: The analysis included 2,947 patients, 1196 (40.6%) with exclusively virtual preoperative visits and 1751 (59.4%) with exclusively in-person visits. Following the implementation of telemedicine in 3/2020, 80.6% of patients had all their preoperative visits conducted virtually via videoconference. Surgical approach included conventional laparoscopy (78.8%), robotic-assisted laparoscopy (3.8%), laparotomy (2.1%), and other gynecologic procedures without abdominal entry (15.3%). The most common procedures were endometriosis excision (43.1%), myomectomy (34.0%), and hysterectomy (24.8%). Composite perioperative complication rates were similar between cohorts (5.9% virtual vs 6.3% in-person, adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.58-1.17). There were no significant differences for major complications (2.3% virtual vs 1.2% in-person, aOR 1.52, 95% CI 0.85-2.74) or minor complications (5.7% virtual vs 6.1% in-person, aOR 0.83, 95% CI 0.59-1.19). Conversion to laparotomy was rare in both groups (0.1% virtual vs 0.2% in-person).

Conclusion: Implementation of virtual preoperative visits within a MIGS practice did not impact composite surgical complication rates. For subspecialized gynecologic surgeons, a virtual preoperative evaluation may offer a safe alternative to the traditional in-person visit.

Objective: The objective of this video is to review a case of a patient that presented to urogynecology clinic for prolapse but was noted to have anterior vaginal cyst. In this video, we review differential diagnosis, embryologic origin of vaginal cyst, excision procedure, imaging, and pathology of the vaginal cyst.

Setting: Urogynecology clinic/operating room PARTICIPANT: Patient who presented with anterior vaginal cyst INTERVENTION: Thirty-four-year-old G0 referred to Urogynecology for a vaginal bulge. On exam, she had a 4 cm anterior vaginal cystic mass. The differential diagnosis for benign vaginal cysts is broad, including Müllerian or Gartner's (mesonephric) ducts, Skene duct, Bartholin gland, epidermal inclusion, or endometriotic cysts, adenosis, or urethral diverticulum [1,2]. Most are secondary to embryological remnants or trauma [3]. Müllerian ducts form the fallopian tubes, broad ligament, uterus, cervix, and upper part of the vagina. Müllerian epithelium is replaced with squamous epithelium of the urogenital sinus; however, Müllerian epithelium can persist anywhere along the vaginal wall. Thus, Müllerian cysts can be found at any location in the vagina [4]. During vaginal cyst work-up, imaging can be helpful to further differentiate the cyst and aid in surgical planning. Our patient had an in-office translabial ultrasound that revealed a fluid-filled vaginal cyst that had possible bladder connection. Pelvic Magnetic Resonance Imaging showed a 4 cm non-communicating fluid-filled cyst that was abutting the bladder in its entirety. We present imaging and a surgical excision video demonstrating the importance of meticulous dissection directly on the bladder wall. The video also presents histopathology slides with bland, endocervical-type columnar epithelium, leading to the final diagnosis of a Müllerian duct cyst.

Conclusion: Vaginal cysts require careful examination and imaging. Understanding their location is crucial for surgical planning, counseling, and successful patient outcomes. VIDEO ABSTRACT.

Objectives: This study compared patients who underwent myomectomy with preoperative uterine artery embolization (UAE) to those who underwent surgery without UAE. The primary objective was to analyze whether preoperative embolization reduces perioperative blood loss and other related complications. The secondary objective was to analyze the long-term outcomes of the 2 techniques in terms of fertility and obstetrical complications.

Design: Observational cohort retrospective study approved by the Brugmann University Hospital's ethics committee (CE2023/79).

Setting: The department of gynecology database was used to extract all myomectomy cases between January 2011 and December 2021. Hysteroscopic myomectomies were excluded.

Patients: 192 patients were included.

Interventions: The population was divided according to the presence or absence of preoperative UAE. The UAE and myomectomy group comprised 95 cases between 2011 and 2020, while the myomectomy-only group consisted of 97 cases between 2014 and 2021.

Measurements and main results: Blood loss was significantly lower when preoperative UAE was performed (175.9 [308.5] mL versus 623.3 [697.5] mL, p-value <.0001). However, there was no significant difference in postoperative haemoglobin, blood transfusion rate or emergent hysterectomy conversions compared to myomectomy as the only treatment. UAE was associated with complications that may result in infertility, such as adhesions (15.3% UAE group vs. 2.2% non-UAE group, p-value .02) and an increased incidence of miscarriage in pregnancies (53.5% UAE group vs. 22.3% non-UAE group, p-value = .01). Furthermore, in cases where a pregnancy did progress following UAE, later obstetrical complications such as abnormal placentation or uterine rupture were common in the series (21.7% UAE group vs. 0% non-UAE group, p-value = .03).

Conclusion: The findings of our study indicate that, other than a lower estimated blood loss (EBL), preoperative UAE does not appear to improve the outcome of myomectomies, while potentially increasing the risk of fertility and pregnancy related complications.

Objective: Fibroids cause significant morbidity, including anemia, pelvic pain, and infertility. It is imperative that healthcare providers are well-versed in the varying treatments available for fibroids. Specifically, uterine artery embolization (UAE) is a treatment that improves anemia, pelvic pain, and quality of life. The purpose of this article is to compare international guidelines on UAE to offer best practices to healthcare providers.

Data sources: Guidelines from the American College of Obstetrics and Gynecology, The Royal College of Obstetricians and Gynaecologists and the Royal College of Radiologists, National College of French Gynecologists and Obstetricians, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Society of Obstetricians and Gynaecologists of Canada, and the National Institute for Health and Care Excellence were reviewed alongside peer-reviewed PubMed articles.

Method of study selection: A comparative review of major international guidelines was conducted to encompass potential geographical, cultural, and societal variances with UAE.

Tabulation, integration, and results: Review of data revealed guidelines agree with many constituents surrounding treatment of fibroids with UAE. Guidelines diverge regarding offering UAE for small fibroids, intracavitary/submucosal fibroids, and pedunculated serosal fibroids with variations on suggested imaging. Most agree that an experienced care team, including a gynecologist and interventional radiologist, should be included. Preoperative antibiotics and intrauterine device removal may be recommended. UAE for patients who desire fertility remains an option after counseling within most guidelines.

Conclusions: UAE is a safe, efficacious, and cost-effective alternative to hysterectomy and myomectomy. Including UAE as a treatment option during the patient counseling process is critical. Guidelines vary based on data interpretation and are based on clinical research and expert opinion. Due to mixed data and lack of randomized controlled trials, organizations differ when offering UAE to patients who wish to preserve fertility. It is vital to note emerging studies supporting the safety of UAE for subsequent pregnancy.

Study objective: Women with Asherman syndrome are at high risk of recurrent adhesions and pregnancy complications. Spontaneous uterine rupture is a rare but life-threatening complication, associated with severe maternal and fetal morbidity and mortality. Uterine ruptures can occur after extended induction of labor or a history of cesarean section, whereas spontaneous uterine rupture in an unscarred uterus is rare. Aim of this study is to evaluate the incidence of spontaneous uterine rupture among women with Asherman syndrome treated by hysteroscopy and without a history of cesarean section.

Design: Prospective cohort study.

Setting: Asherman Expertise Center of the Spaarne Gasthuis, The Netherlands.

Patients: Women were defined by as patients with Asherman syndrome when they had one or more clinical features and the presence of hysteroscopically confirmed intrauterine adhesions.

Interventions: Hysteroscopic adhesiolysis and a second-look hysteroscopy two months after the initial procedure.

Measurements and results: Data on the severity of adhesions and ongoing pregnancy after treatment were collected prospectively. A total of 428 women with Asherman syndrome were included, 4 women (0.9%) experienced spontaneous uterine rupture. The timing varied, none of the affected women were in active labor and the occurrence of uterine rupture was not related to the severity of adhesions. Ruptures were all found in the fundus. One woman had a history of perforation of the uterine wall located in the fundus. Neonatal outcomes were poor, two cases had intrauterine neonatal death and two cases had long-term lifelong disability. One woman had a second uterine rupture.

Conclusion: Women with Asherman syndrome are at risk of uterine rupture, a pregnancy complication with significant consequences that is challenging to predict and may also be associated with history of uterine perforation. Clinicians should be aware of this risk in women treated with hysteroscopic adhesiolysis and consider counseling these patients accordingly prior to treatment.